Management of Pterygoid Venous Plexus Hemorrhage during Resection of a Large Juvenile Nasopharyngeal Angiofibroma: A Review of 27 Cases

Abstract

We retrospectively reviewed the cases of 27 patients who experienced intraoperative bleeding during resection of a large (Fisch type III or IV) juvenile nasopharyngeal angiofibroma (JNA). Of this group, 16 patients had a type III JNA and 11 had a type IV tumor. The degree of hemorrhaging during excision of these JNAs varied greatly among individual patients. The amount of blood lost ranged from 200 to 5,000 ml (mean: 1,800) in the type III cases and from 700 to 8,000 ml (mean: 2,850) in the type IV cases. In 5 of these cases, both intraoperative observations and imaging data suggested that an important factor in the blood loss was damage to the pterygoid venous plexus (PVP). The PVP communicates with the cavernous sinus, ophthalmic vein, maxillary vein, and facial vein; no valve exists between these veins. In patients with a large JNA, the PVP is usually compressed by or adherent to the tumor. When a PVP is seriously damaged during removal of a JNA, hemorrhaging can be very profuse. Therefore, a suitable surgical approach and appropriate hemostatic procedures should be used to prevent or manage PVP hemorrhage as effectively as possible. We also describe in greater detail 5 typical cases of JNA excision that did (n = 3) and did not (n = 2) involve PVP damage.

Variations in the venous supply of the floor of the oral cavity: Assessment of relative hemorrhage risk during surgery

“…Compared with veins running independently, it will probably be difficult to stop bleeding in the venous plexus. Actually, management of pterygoid venous plexus hemorrhage is quite important during the resection of a large juvenile nasopharyngeal angiofibroma (Chang et al, 2013). Since the floor of the oral cavity contains another venous plexus, management of it is recommended to avoid postoperative bleeding.…”

Endoscopic Endonasal Approach to the Lateral Wall of the Cavernous Sinus: A Cadaveric Feasibility Study

“…The bony corridor to the MCF could have extended further beyond V3 and the anterolateral triangle, but this would necessitate violating the muscular compartment of the infratemporal fossa, with possible troublesome pterygoid muscle bleeding in vivo. 26 The area between V2 and V3 forms a triangle representing the pterygoid base. The vidian canal exhibited wide side-to-side variation in our study, which was similarly documented in other studies.…”

“…The bony corridor to the MCF could have extended further beyond V3 and the anterolateral triangle, but this would necessitate violating the muscular compartment of the infratemporal fossa, with possible troublesome pterygoid muscle bleeding in vivo. 26…”

A Comprehensive Review on Hanugata Avedhya Sira

“…The amount of blood loss ranged from 200 to 5,000 ml (mean: 1,800) in the type III cases and from 700 to 8,000 ml (mean: 2,850) in the type IV cases. [30] Guinto et al described their use of the zygomatic trans-mandibular approach in the treatment of 10 patients with massive tumours that were localized in the infratemporal fossa. On drilling into the middle fossa, they noted profuse bleeding around the third vertebra, which was caused by the numerous veins in the pterygoid plexus.…”