Evolution in the Surgical Techniques in Management of Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is a benign, locally aggressive rare tumor representing ~0.05% of head and neck tumors in the western world but more common in the Indian subcontinent and in Egypt. The typical presentation is a male teenager with recurrent epistaxis and nasal obstruction. JNA has a propensity for local destruction and intracranial or intraorbital extension. Its highly vascular nature makes complete resection a tedious procedure with further concern for copious blood loss. Surgery is the mainstay of management of these tumors. Before 1980, various open surgical techniques have been used for the resection of this tumor. With the advent of endoscopes, microdebrider, and coblation, the surgical techniques have become more endoscopic and with minimal morbidity in these cases. We are presenting our experience in this bleeding tumor resection from open to endoscopic approaches. The role of embolization especially in Fisch stage I and stage II is more of a surgeon’s preference than a rule.

Twenty-two patients with JNA were treated in our institution from 2000 to 2008. Twenty patients underwent total resection using modified midfacial-degloving-technique with transmaxillary approach. Two patients, stage IV, underwent partial resection followed by radiation. The operated patients in the follow-up showed no recurrence. The radiated patient showed stable tumor.

From 2008, we have shifted more toward endoscopic approach in the management of these tumors. We operated on 10 patients with ages ranging between 12 and 21 years with a mean of 17.5 years. Tumor size was between 3 to 7 cm. with Fisch type 1 to IIIa. The estimated blood loss was from 80 to 1,050 cc. All surgeries were done using either Evac Extra XP or Procise XP coblator wands with endoscopic assistance.

Endoscopic techniques have greatly influenced the management of smaller tumors. To date, their role in treating larger tumors may be as an adjunct to standard open techniques. There is a steep learning curve in endoscopic management of these bleeding tumors and navigating the endoscopes and instruments in the narrow confines of anterior skull base

No conflict of interest has been declared by the author(s).