Endoscopic resection of juvenile nasopharyngeal angiofibroma: How and when

Aim of the study: The authors reviewed a series of patients with juvenile nasopharyngeal angiofibroma (JNA) treated by an endoscopie approach, with the intent to analyze the possibilities and limitations of the surgical technique. Patients and methods: From January 1994 to December 2000, 14 patients with JNA were treated by an endoscopie approach at the University of Brescia. All were males, with a mean age of 16 years (range, 13-30). Three of them had already been treated for the lesion by an external approach at other institutions. Preoperative workup included CT, MR and angiography, which was performed in conjunction with embolization using polyvinyl alcohol particles 72 to 24 hours before surgery. With some slight differences in the single patient, the basic surgical steps were: uncinectomy with preservation of the frontal recess, partial or total middle turbinectomy, anterior and posterior ethmoidectomy, wide middle antrostomy, partial resection of the posterior wall of the maxillary sinus, sphenoidotomy, isolation and clipping of the internal maxillary artery, transnasal or transoral removal of the lesion, and drilling of the pterygoid process. All patients were followed prospectively by endoscopie and radiologie (MR) evaluations performed at regular intervals (every four months during the first year and subsequently after six months). Results: According to Andrews's (1989) staging system, 2 patients had a type I JNA, 8 a type II, 3 a type IIIA, and 1 a type IIIB. Angiography demonstrated that the vascular supply to the lesion was strictly unilateral in 11 patients and bilateral in 3. Intraoperative blood loss ranged from 80 to 600 ml (mean, 354). During the follow-up (range, 12-84 months; mean, 39), only 1 patient, who had been treated for a type I JNA with a very conservative dissection, presented a residual lesion, 16 mm in diameter, 24 months after surgery. Conclusions: Based on our experience, the endoscopie approach is a safe and effective technique that allows removal with a low morbidity of small and intermediate-size JNAs without extensive involvement of the infratemporal fossa and cavernous sinus. Advanced lesions are more appropriately managed by external approaches.