Endoscopic graduated multiangle, multicorridor resection of juvenile nasopharyngeal angiofibroma: an individualized, tailored, multicorridor skull base approach

Abstract

OBJECT 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 JNAs with greater surgical freedom and decreased incidence of facial deformity and scarring. METHODS This report describes a graduated multiangle, multicorridor, endoscopic approach to JNAs that is illustrated in 4 patients, each with a different tumor location and extent. Four different surgical corridors in varying combinations were used to resect JNAs, based on tumor size and location, including an ipsilateral endonasal approach (uninostril); a contralateral, transseptal approach (binostril); a sublabial, transmaxillary Caldwell-Luc approach; and an orbitozygomatic, extradural, transcavernous, infratemporal fossa approach (transcranial). One patient underwent resection via an ipsilateral endonasal uninostril approach (Corridor 1) only. One patient underwent a binostril approach that included an additional contralateral transseptal approach (Corridors 1 and 2). One patient underwent a binostril approach with an additional sublabial Caldwell-Luc approach for lateral extension in the infratemporal fossa (Corridors 1–3). One patient underwent a combined transcranial and endoscopic endonasal/sublabial Caldwell-Luc approach (Corridors 1–4) for an extensive JNA involving both the lateral infratemporal fossa and cavernous sinus. RESULTS A graduated multiangle, multicorridor approach was used in a stepwise fashion to allow for maximal surgical exposure and maneuverability for resection of JNAs. Gross-total resection was achieved in all 4 patients. One patient had a postoperative CSF leak that was successfully repaired endoscopically. One patient had a delayed local recurrence that was successfully resected endoscopically. There were no vascular complications. CONCLUSIONS An individualized, multiangle, multicorridor approach allows for safe and effective surgical customization of access for resection of JNAs depending on the size and exact location of the tumor. Combining the endoscopic endonasal approach with a transcranial approach via an orbitozygomatic, extradural, transcavernous approach may be considered in giant extensive JNAs that have intracranial extension and intimate involvement of the cavernous sinus.

Transnasal endoscopic partial maxillectomy: Operative nuances and proposal for a comprehensive classification system based on 1378 cases

“…In rhinosinusitis not previously operated, the inferior part of the uncinate process is removed to expose the natural ostium of the maxillary sinus, which can be regularized in supports endoscopic endonasal surgery as the gold standard in the treatment of these benign lesions. 14,[30][31][32][33] Our series confirmed these findings, suggesting at least that a wide opening of the maxillary sinus (TEPM type 1) is advisable for the management of benign and malignant sinonasal tumors, even those not directly invading the maxillary sinus, in order to control surgical landmarks and thus help the surgeon in the tumor resection and improve the chances of identifying recurrences of disease under endoscopic control during the postoperative follow-up. In selected cases, the lateral wall of the nasal cavity can be shifted medially providing adequate access to the anterolateral maxillary sinus portion while preserving the inferior turbinate and nasolacrimal duct.…”

Nasal juvenile angiofibroma: Current perspectives with emphasis on management

“…Even limited intracranial penetration/dural invasion may be endoscopically approachable . The debate continues and using endoscopy combined with transnasal, transfacial, and transcranial approaches may be a reasonable compromise …”

Combined endoscopic and transoral resection of a high‐staged juvenile nasopharyngeal angiofibroma: A pictorial essay

“…We operated on a 14‐year‐old male with an extensive high‐stage dumbbell‐shaped JNA involving the infratemporal fossa (ITF), orbit, buccal space, and intracranial extension into Meckel's cave, staged as Andrews‐Fisch IIIb, Radkowski IIIa, or UPMC V. Large tumors with this pattern of extensive spread would usually involve extensive open approaches such as a facial translocation, maxillary swing approach, or an orbitozygomatic craniotomy 10 . However, we describe a single‐stage, combined endoscopic and transoral approach with minimal morbidity and relative technical ease and good postoperative outcome.…”