Angiofibroma: an outcome review of conventional surgical approaches

Abstract

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasopharynx, and for its treatment, many surgical approaches have been recommended. However, selecting the appropriate one for the tumor in an advanced stage is still controversial. In this study, we evaluate the rate of recurrence of JNA and its relationship to the preoperative stage as well as various surgical approaches. Thirty-seven patients with pathologically proven JNA were retrospectively analyzed. For each patient, data were obtained regarding the primary extension, various surgical approaches and rate of recurrence. Seven patients were in stage III with intracranial extensions. Two of these patients had symptomatic recurrence that needed surgery. Three of them were disease free, and in two cases residues were demonstrated that were asymptomatic and were chosen only to be observed. Among different surgical approaches used, the transpalatal resulted in 1 recurrence out of 14 patients treated with this approach when the lesion was limited to the nasal cavity, nasopharynx and paranasal sinuses (stage I). No recurrence was observed with the use of this approach with lesions with minimal extension to the pterygopalatine fossa (stage IIA). But among three patients with intracranial extension who were treated with this approach, two resulted in symptomatic recurrence; however, using the Lefort I surgical technique, no evidence of recurrence was observed in the two patients in stage III who were treated with this approach. Involvement of the orbit, middle cranial fossa and base of the pterygoid by the primary JNA results in a higher incident of recurrent tumor. Among different surgical techniques, the lowest recurrence rate is seen either in the transpalatal approach when the tumor is limited to the nasopharynx with extension to the nasal cavity or paranasal sinuses or with the Lefort I approach when skull base invasion is present.

Experiência de sete anos em pacientes com angiofibroma nasofaríngeo juvenil

“…[24][25] In most cases, the clinical presentation of the angiofibroma comprises the triad nose block, epistaxis, and a nasopharyngeal mass, which was similar to our findings in the study and in previously published papers. 13,14,26,27 The diagnosis of angiofibroma is given based on the clinical history, the physical examination, and nasal endoscopy; imaging studies, such as computed tomography, may add further information, as was done in the patients comprising this study. The correlation between preoperative staging based on computed tomography and the Fisch criteria 11 was possible in the 16 cases of this study.…”

“…6 In the present study, all patients were male, and the mean age at the time of diagnosis was 16.8 years, which is similar to other published studies. [13][14][15]20,23 Genetic studies have demonstrated a close relation between these angiomas and androgen receptor expression, suggesting that this tumor is androgen-dependent. This could explain why the prevalence is higher in males.…”

“…Arteriography is done to assess the vascular supply in larger tumors and to make it possible to embolize these vascular lesions to reduce intraoperative bleeding. [14][15][16] Several tumoral or non-tumoral diseases may cause nasal block and epistaxis, which may be taken for an angiofibroma. The following conditions should be taken into account in the differential diagnosis: inflammatory polyps, angiomatous polyps, nasopharyngeal cysts, nasopharyngeal malignancies, nasopharyngeal fibrosarcomas and fibromas, upper maxillary malignancies, nasal fossa stesioneuroblastoma, adenoid hypertrophy, cervical vertebra cordomas, and retropharyngeal ganglia tuberculosis.…”

Tratamento cirúrgico de nasoangiofibroma sem embolização

“…Although it is considered a benign neoplasm, this tumor is not encapsulated, may lead to local destruction and has high relapse rates1. This vascular tumor emerges mainly from the sphenopalatine foramen and may extend all the way to the middle cranial fossa 3,4 . According to the scheme proposed by Fisch 5 , these tumors may be contained within the nasal cavity and nasopharynx (I), invade the face sinuses or the pterygopalatine fossa (II), expand towards the infratemporal fossa, orbit, and parasellar region (III) or present intracranial invasion (IV).…”

“…Intraoperative bleeding may occur in any of the approaches and has been one of the main perioperative complications. Preoperative arterial embolization has been used systematically to reduce the amount of bleeding and the use of blood byproducts during surgery with good results 4,7 . However, there is no consensus as to the routine use of preoperative embolization, given its high cost and inconsistent availability of the procedure in care centers.…”