Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management.

BACKGROUND: Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas. METHODS: We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension. AIMS: Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery. RESULTS: Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes. CONCLUSIONS: The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

Combined endoscopic endonasal and sublabial transmaxillary approaches for resection of intracranially extended juvenile nasopharyngeal angiofibroma.

BACKGROUND: Juvenile nasopharyngeal angiofibromas (JNAs) are rare, benign, and locally invasive nasopharyngeal tumors. Endoscopic endonasal resection is effective, non-invasive, with low complication rates. Until recently, endoscopic resection was not suitable for intracranially invasive tumors. PURPOSE/METHOD: We describe resection steps of an intracranially extending JNA with a combined endoscopic endonasal and endoscopic-assisted sublabial transmaxillary approaches. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video. CONCLUSION: Surgical excision of JNAs by a combined endoscopic endonasal and sublabial transmaxillary approaches represents a safe and effective treatment for selected intracranially invasive JNA.

Extended Endonasal Endoscopic (EEE) Surgery with Almost No Use of Adjuvant Radiotherapy for Juvenile Nasopharyngeal Angiofibroma (JNA).

Background and Objectives: Juvenile nasopharyngeal angiofibroma (JNA) is an angiomatous hamartoma of the nasal cavity. It is a benign but locally aggressive vascular tumor of the nasopharynx affecting adolescent males. Many surgical procedures are in practice, but the extended endonasal endoscopic (EEE) approach for JNAs is a suitable and effective technique. Materials and Methods: Fifteen adolescent patients having JNA who underwent extended endonasal endoscopic (EEE) surgery from January 2010 to January 2022 were studied retrospectively. Patients having residual and recurrent JNAs and those who underwent surgery other than EEE were excluded. Results: The average age of the patients was 18.3 years of age. A total of six patients (40%) each had stage V and IV while three patients (20%) had stage III JNAs. Gross total removal was achieved in eight (53.3%) patients and seven (43.7%) had partial removal. There was no per or postoperative mortality. All the patients had at least 3 years of postoperative follow-up and during follow-ups, seven patients were found to have residual tumors, and two had recurrences. Discussion: During the last decades, the endoscopic approach for the resection of JNAs has gained increasing popularity due to its obvious advantages over transfacial approaches. The magnified and angled field of view "behind the corner" helping in a more complete inspection for the resection and shorter hospitalization time makes it a better choice than the other approaches. Conclusions: Endoscopy is an excellent approach for primary JNA. It allows well visualization and precise removal of the angiofibroma. An endoscopic multiangle, multicorridor skull base approach including Denker's anteromedial maxillotomy is suitable and preferable for the resection of extensive JNAs.

Preoperative emobilisation of juvenile nasopharyngeal angiofibroma.

INTRODUCTION: Juvenile nasopharyngeal angiofibroma(JNA) are highly vascular benign tumours originating in the sphenopalatine fossa and may extend to the pterygopalatine fossa, paranasal sinuses, and nasal cavity. The management of JNA has evolved greatly with development of endoscopy. Treatment modality has changed from open approach to endoscopic approach due to various advantages offered by the endoscopic approach. Bleeding during the surgery can compromise the exposure and surgical excision of JNA endoscopically. There have been many techniques to decrease intraoperative bleeding including external carotid ligation, hypotensive anaesthesia and more recently embolization of the feeding vessels. Embolization of the tumour has made the endoscopic excision of JNA easier because of less bleeding. This study was taken to find out the outcomes of surgical excision of JNA after embolization. METHODOLOGY: We retrospectively reviewed 22 histopathological proven JNA cases that underwent preoperative embolization followed by resection during the period of June 2015 to December 2020 in our tertiary care hospital. From the records demographic, clinical, radiological imaging (CECT nose and PNS), angiographic, pre-operative embolization and operative details were evaluated. RESULT: In the present study a total of 22 cases of angiofibroma were taken up for surgical excision after embolization. A complete endonasal endoscopic resection could be done in 21/22 cases with average operative time of 141 minutes (80 minutes-190 minutes range). The mean blood loss during surgery was 1163 ml (Range 500 ml- 1900 ml). In 7/22 (31.81%) subjects required intraoperative blood transfusion. No perioperative surgical complications occurred. CONCLUSION: Endoscopic excision of JNA has now become the primary operative technique and pre operative embolization in such cases can reduce the intraoperative time, blood loss and tumour relapse rate. It is a relatively safe procedure in a hand of an expert and must be done where ever available.

Electron microscopy of juvenile nasopharyngeal angiofibroma: clinical and histopathological correlates.

BACKGROUND: The histological and electron-microscopic (EM) characteristics of juvenile nasopharyngeal angiofibroma (JNA) have been described but no study has compared them with one another or with clinical features. The objective is to compare ultrastructural characteristics of JNA with clinical parameters. METHODS: This prospective study included histology of 21 samples of which only 13 underwent transmission-EM. Four clinical parameters (age, duration, epistaxis, recurrence), three radiological-staging, 13 histological and 15 EM characteristics were considered. A descriptive analysis for association of these characteristics and also with clinical parameters was attempted. Furthermore statistical analysis of clinical and radiological categories with respect to frequencies of ultrastructural characteristics was also undertaken. RESULTS: Dense-intranuclear-inclusions (DNI) and peripheral-nuclear-irregularities were universally encountered while other very prominent features were nuclear-blebs-and-pockets, myoid-features, thin-vessel-wall (TnVW), irregular-vascular-contour (IVC) and fibrous-stroma (FS). Statistical significance was obtained between recurrence with histology (p = 0.04) and Fisch staging with EM (p = 0.001). While muscle-in-vessel-wall, thick-vessel-wall, mast-cells, stellate-stromal-cells and cellular-stroma predominated in recurrent cases, the upfront disease showed predominance of scar-like-stroma, fusiform-stromal-cells, IVC, TnVW, FS, organised-collagen-bundles and less-cellular-stroma. A very unique Rod-like-structures were appreciated in the cytoplasm of the fibroblast for the first time. CONCLUSIONS: While histological parameters of recurrence need further validation, a larger sample may better define histopathological surrogate for predicting intracellular dynamics that may further correlate with underlying cellular stresses. Hence an 'ultrastructural staging' may better customise treatment protocol and prognosis. Furthermore 'characteristic' unique rods need to be further investigated along with validation of viral aetiology for DNI.

Nasopharyngeal rhinosporidiosis with intracranial extension masquerading as juvenile angiofibroma: an unusual entity.

Rhinosporidiosis is a chronic fungal inflammatory disease prevalent in India and Sri Lanka. Its manifestations are mostly nasal and extranasal lesions are relatively rare. Occasional atypical presentations of this disease lead to diagnostic dilemma. Herein we report on a case of nasopharyngeal rhinosporidiosis having extensive involvement of paranasal sinuses along with intracranial extension which mimicked radiologically as juvenile nasopharyngeal angiofibroma. To our knowledge, this is the first reported case of rhinosporidiosis having intracranial extension. We discuss the pathology, treatment and briefly review the literature of this rare disease.

EBV-Positive Plasmacytomas Involving a Nasopharyngeal Angiofibroma in an Adolescent.

We report comprehensive characterization of an unusual collision tumor comprising extramedullary plasmacytomas and nasopharyngeal angiofibroma in a pediatric patient, which has yet to be reported. Histologically, the nasopharyngeal angiofibroma showed typical morphology with a diffuse, dense plasmacytic infiltrate in the stroma. The neoplastic plasma cells showed a spectrum of well-differentiated, plasmablastic, and anaplastic morphology, Epstein-Barr virus encoded RNA (EBER) positivity, and aberrant immunophenotype. Fluorescence in situ hybridization using a plasma cell myeloma targeted panel detected gains of 1q21.3 (CKS1B, x3), 3q27 (BCL6, x4), and 11q22.3 (ATM, x3), but no rearrangement of ALK and MYC. A 50-gene next generation sequencing lymphoma panel failed to detect any pathogenic mutation. Plasmacytoma with EBER positivity and plasmablastic morphology must be distinguished from plasmablastic lymphoma due to different clinical management and prognosis. This case highlights the importance of a thorough pathological evaluation of a mass lesion with synchronous neoplastic processes.

Midfacial degloving for juvenile angiofibroma: A case-series of 21 adult males: An alternative to the endoscopic approach and when it should be considered.

OBJECTIVES: To describe the midfacial degloving approach and compare the varying surgical approaches to juvenile angiofibromas. To demonstrate the efficacy of midfacial degloving in treating large juvenile angiofibromas in a unique patient cohort. DESIGN: A retrospective case-series between 2006 and 2019. SETTING: All patient care was undertaken at a regional skull base referral centre. PARTICIPANTS: Twenty-one male patients with a median age of 18 (range 16-45 years). MAIN OUTCOME MEASURES: Presenting symptoms, imaging, stage, age at operation, residual disease, estimated blood loss and operative time were all recorded. Postoperative outcomes included complications, length of stay and recurrence. RESULTS: The median surgical time was 105 minutes (range 55-219 minutes), median estimated blood loss 600 mls (range 150-900 mls) and median length of stay was 4 days (range 2-13 days.). Complications included two episodes of epistaxis, one requiring packing and one return to theatre. 14% (3/21) of patients had residual disease, none requiring further treatment and one patient had recurrence. CONCLUSIONS: MFD for JNA in our series resulted in low recurrence rate and no progression of residual disease. The approach has been successful in our cohort of patients and is an option in males over the age of 16 years, with JA extending beyond the nasopharynx and sinuses, involving the infratemporal fossa, cavernous sinus or orbital region.

The risk factors for residual juvenile nasopharyngeal angiofibroma and the usual residual sites.

OBJECTIVE: Juvenile nasopharyngeal angiofibroma (JNA) is non-metastasizing but potentially locally destructive tumor of the nasopharynx. It can destroy the skull base and invade into the cerebrum. Surgical management is the primary standard but residual disease is always a risk factor. We aimed to determine the risk factors for residual disease and usual sites for these residual tumors. METHODS: The medical records of 131 patients (mean age 17.6 ±â€¯6.8, range 9-71 years) with histologically proven JNA were retrospectively analyzed. The surgeries were all nasal endoscopic approaches, with or without assistant incision. RESULTS: The prevalence of residual disease was 16.8%. Risk factors associated with JNA recurrence included tumor stage, intraoperative bleeding, and the year in which the operation was performed. The pterygoid canal, pterygoid process, and pterygopalatine foramen were the most frequent locations for residual tumor. CONCLUSION: Surgical management should take particular care for the pterygoid canal, petrygoid process, and pterygopalatine foramen. Contrast-enhanced CT and MRI are effective tools to evaluate complete JNA excision in the first two days after primary surgery. Careful exploration of these areas may be the key to avoid residual JNA.

Efficacy and safety of preoperative internal maxillary arterial embolization with gelfoam for nasopharyngeal angiofibroma.

PURPOSE: To investigate the efficacy and safety of preoperative internal maxillary arterial embolization with gelfoam particles in patients with nasopharyngeal angiofibroma. MATERIALS AND METHODS: We retrospectively reviewed a total of 27 consecutive patients with pathologically confirmed nasopharyngeal angiofibroma from August 2006 to September 2018. Of the 27 enrolled patients, 10 patients received surgical excision alone; 17 patients received preoperative internal maxillary arterial embolization followed by surgical excision. Embolic agents were gelfoam particles. RESULTS: The mean volume of intro-operative blood loss was 385.3 ml in patients with preoperative arterial embolization, which was significantly lower than 1215.0 ml in the patients without preoperative arterial embolization (P < 0.001). The mean surgical time was shorter in patients with preoperative arterial embolization than in the patient without preoperative arterial embolization, but the difference had no statistical significance (205.0 vs 264.5 min, P = 0.064). Neurological complications such as facial palsy or vision loss or hemiplegia were not observed in patients with preoperative arterial embolization. CONCLUSION: Internal maxillary artery embolization with gelfoam particles suffices to provide an effective and safe adjuvant procedure for surgical excision of nasopharyngeal angiofibroma.

Molecular interactions in juvenile nasopharyngeal angiofibroma: preliminary signature and relevant review.

BACKGROUND: The molecular profile of juvenile nasopharyngeal angiofibroma (JNA) is extremely variable. In absence of established molecular signature the molecular targeting seems difficult for this heterogeneous disease. To establish a basic molecular signature, this paper analyses the interaction of 7 markers according to their ranks as per the decreasing scale of molecular expression. MATERIALS AND METHODS: Fourteen samples of JNA were obtained following surgical excision and mRNA expressions were established through real-time polymerase chain reaction (RT-PCR) for vasculoendothelial growth factor (VEGF), fibroblastic growth factor (FGF), c-Kit, c-myc, Ras, platelet-derived growth factor (PDGF) and tumor suppressor gene p53. Nasal polyp was taken as control. The quantitative expressions for every marker were ranked on a decreasing scale and were compared by Spearman's rank correlation test to define the statistically significant interaction. An attempt was also made to overview the basic clinical parameters (age, duration of symptoms, radiological staging, intraoperative haemorrhage and tumor-volume/weight) associated with enhanced molecular expressions for every marker. RESULTS: Five significant molecular interactions were identified on the basis of rank-correlation: (1) FGF/VEGF (p < 0.01); (2) Ras/FGF (p < 0.01); (3) Ras/VEGF (p < 0.001), (4) FGF/c-Kit (p < 0.05); (5) c-Myc/p53 (p < 0.05). These basic 'molecular signatures' suggested a preliminary 'molecular classification'. The implication of the interactions between FGF, VEGF and Ras were the most outstanding observation that not only revealed a direct relationship but were also consistent with the clinical behaviour. In addition, a non-significant interaction was identified with c-Myc/PDGF and also an inverse relationship between FGF/c-Kit. CONCLUSIONS: FGF, VEGF, and Ras being significantly interrelated seemed to be the 'most soft' molecular targets for JNA. The other targets observed included FGF/c-Kit and c-Myc/p53 interactions that seemed equally important but only after VEGF/FGF/Ras complex per se. These preliminary signatures are likely to provide a background for further expansion of the molecular classification of JNA.

Newly detected DNA viruses in juvenile nasopharyngeal angiofibroma (JNA) and oral and oropharyngeal squamous cell carcinoma (OSCC/OPSCC).

PURPOSE: Approximately 20% of cancers are estimated to have a viral etiology. We aimed to investigate whether DNA of 8 human parvoviruses [bocavirus 1-4 (HBoV1-4), parvovirus B19 (B19V), protoparvoviruses (bufa-, tusa-, and cutavirus)] and 13 human polyomaviruses (HPyV) can be detected in oropharyngeal and oral cavity squamous cell carcinoma (OPSCC/OSCC), and in juvenile nasopharyngeal angiofibroma (JNA) tissue samples. METHODS: Fresh samples of seven JNA tissues and ten paired tissues of OSCC/OPSCC tumor and adjacent healthy tissues were collected. DNA extraction and real-time PCRs were performed to detect HBoV1-4, B19V, bufa- tusa- and cutavirus, and HPyV genomes. RESULTS: JNA specimens were negative for all parvoviruses tested, whereas one JNA sample was Merkel cell polyomavirus (MCPyV) DNA positive. The OSCC/OPSCC samples were negative for the human protoparvoviruses, HBoV1-4, and all human polyomaviruses, except for one patient that was MCPyV DNA positive in both healthy and tumor tissues. Seven OSCC/OPSCC patients were positive for B19V DNA, three of them in both healthy and cancerous tissues and three in only healthy tissues. Three of the B19V DNA-positive patients harbored viral genotype 1, three genotype 2, and one genotype 3B. CONCLUSIONS: These are the first reports of MCPyV and B19V DNA being detected in JNA and OPSCC. The significance of viral DNA positivity is unclear. B19V DNA is known to remain in the tissues lifelong, however, it is of interest that there are some patients with B19 DNA in healthy tissue, but not in the corresponding cancer tissue.

[Primary juvenile nasal angiofibroma in a 38 year-old male (case report)]. / Pervichno vyiavlennaia iunosheskaia angiofibroma osnovaniia cherepa u muzhchiny 38 let (klinicheskoe nabliudenie).

Juvenile nasal angiofibroma (JNA) is a benign, fibro-vascular, locally aggressive tumor with invasive growth patterns and high probability of recurrence. JNA present exclusively in adolescent boys between 9 and 19 years of age, total about 0.05% of head and neck tumors. 143 patients with JNA had been treated surgically from 2002 to August 2018 at N.N. Burdenko National Medical Research Center for Neurosurgery. All patients (primary and recurrences) were males of the age 7-38 years (16.1 [11.3; 19] years). The age of patients with primary JNA was less than 18-year old, of the exception of presenting case. There are more and more publications about case reports and successful treatment series of JNA. However, after detailed review the literature we revealed some kind of confusion: there are case reports of JNA in women and elderly people, JNA in patients with some systemic diseases, JNA with different places of origin and different morphological structure. In this paper we present a very rare case of 38 year-old male with pure primary JNA, accidentally diagnosed on CT and pathologically proven after endoscopic removal. This case confirms the possibility of detecting the JNA in adult men and explains why proper diagnosis of angiofibromas is necessary. The unique case and the literature review are presented.

Cumulative sum analysis of the learning curve for endoscopic resection of juvenile nasopharyngeal angiofibroma.

BACKGROUND: To determine the learning curve with cumulative sum analysis for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and investigate whether the surgeon's expertise is a risk factor for recurrence. MATERIALS AND METHODS: We reviewed the medical records of patients with JNA who underwent endoscopic or endoscopic-assisted surgery between 2006 and 2015. We used cumulative sum (Cusum) analysis to plot the learning curve for operation time versus chronological sequence, and verified the Cusum curve by risk-adjusted Cusum (RA-Cusum) analysis. We identified three phases of expertise. The recurrence rate was analyzed using the Kaplan-Meier method and log-rank tests. A multivariable Cox regression analysis was performed to identify the independent risk factors for recurrence. RESULTS: We included 154 JNA patients with a median age of 16 years. The surgeon overcame the learning curve after case 80 with increasing surgical efficiency and competence. The learning curve plotted by Cusum analysis divided the cases into three phases: phase 1, accumulation of initial experience (cases 1-41); phase 2, further accumulation of experience (cases 42-117); and phase 3, mastering the procedure (cases 118-154). Pearson's χ2 tests showed that tumor stage (P = 0.021), blood loss (P = 0.001), operation time (P < 0.001), and phase (P < 0.001) were associated with recurrence. The log-rank test showed that time to recurrence was significantly shorter in phase 1 than in phases 2 and 3. Blood loss and phase were independently prognostic factors for time to recurrence, with P values of 0.023 and 0.009, respectively. The RA-Cusum analysis identified two inflection points of the curve at case 44 and 83, and verified the results of Cusum analysis. CONCLUSION: Surgical experience and competence with endoscopic resection affect the recurrence rate in JNA patients. LEVEL OF EVIDENCE: 4.

Trigeminocardiac reflex during endoscopic juvenile nasopharyngeal angiofibroma surgery: an appraisal.

Juvenile nasopharyngeal angiofibroma is a locally aggressive benign tumour which has propensity to erode the skull base. The tumour spreads along the pathways of least resistance and is in close proximity to the extracranial part of trigeminal nerve. Advancements in expanded approaches for endoscopic excision of tumours in infratemporal fossa and pterygopalatine fossa increase the vulnerability for the trigeminocardiac reflex. The manipulation of nerve and its branches during tumour dissection can lead to sensory stimulation and thus inciting the reflex. The aim of our study is to report the occurrence of trigeminocardiac reflex in endoscopic excision of juvenile nasopharyngeal angiofibroma. To describe the occurence of trigeminocardiac reflex during endoscopic endonasal excision of juvenile nasopharyngeal angiofibroma. We studied the occurrence of TCR in 15 patients (out of 242 primary cases and 52 revision cases) operated for endoscopic endonasal excision of JNA. The drop in mean arterial blood pressure and heart rate were observed and measured. To the best of our knowledge of English literature, this is the first case series reporting TCR as complication in endoscopic excision of JNA. occurence of this reflex has been mentioned in various occular, maxillofacial surgeries but its occurence during endoscopic excision of JNA has never been reported before. Manifestation of trigeminocardiac reflex during surgery can alter the course of the surgery and is a potential threat to life. It is essential for the anesthetist and surgeons to be familiar with the presentations, preventive measures and management protocols.

Angiofibroma In A 50-Year-Old Patient.

Juvenile Angiofibroma (JNA) is a benign tumour that tends to bleed and occur in the nasopharynx with most cases occurring in pre-pubertal and adolescent males 10-20 years. We present the case of a 50-year-old male shopkeeper who consulted the ENT out patients' department (OPD) of Khyber Teaching Hospital (KTH) with the chief complaint of right sided nasal obstruction for the last 2.5 months which was associated with two episodes of epistaxis and diplopia which started 2 months back. He complained of right sided frontal and periorbital pain for the last 15 days. Past medical and surgical history was insignificant. Computerized Tomography (CT) scan without contrast and magnetic resonance imaging (MRI) showed finding consistent with a pedunculated tumour like growth. After baseline investigations, surgery was done and a Wilson's incision was given and the mass was excised and sent to the lab for histopathological report which showed angiofibroma. The age of the patient shows that this is a very rare case of angiofibroma. Dissection of such tumours is important as they have propensity to bleed. Excision along with biopsy is the method of choice. Proper surgical techniques and use of better medical technology are required to make and early diagnosis. Further studies/case reports around the world would assert our findings that a nasopharyngeal angiofibroma can also be found in middle aged men.

Association between vascular supply, stage and tumour size of juvenile nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular tumour seen in adolescent males. To study the vascular pattern of these tumours, we retrospectively reviewed the records of patients with JNA who underwent preoperative angiography. Most (82.2 %) of the 45 patients assessed were Radkowski stage III with a mean size of 5.29 cm. There was a significant association between tumour stage and size (p = 0.029). Ten different vessels were seen to supply these tumours. All tumours had primary supply from the distal third of the ipsilateral internal maxillary artery (IMA). Accessory vessel supply was chiefly from the Vidian branch of internal carotid artery (ICA) (55.6 %). Stage III tumours were supplied by a greater number of feeding vessels than earlier stage tumours (p < 0.01). Larger tumours were more likely to have ICA supply (p = 0.04). Bilateral supply was seen in 48.7 %. However, there was no predominance of bilateral over ipsilateral IMA supply even in advanced stage tumours. One patient in our series was found to have a caroticocavernous fistula. Residual or recurrent tumours were characterized by new vasculature (100 %) and greater accessory supply from the ipsilateral ICA (85.7 %). Our study highlights the fact that surgical planning cannot be dependent on staging alone and should include preoperative assessment of tumour vasculature by angiography.

Invasive growth patterns of juvenile nasopharyngeal angiofibroma: radiological imaging and clinical implications.

Juvenile nasopharyngeal angiofibroma is a benign lesion with locally aggressive nature. Knowledge of its typical growth patterns is crucial for precise preoperative staging and adequate preoperative patient counseling. This pictorial essay focuses on characteristic radiological features and paths of invasive growth of this rare tumor. Also, the impact of accurate preoperative evaluation of tumor extensions on surgical planning and results of treatment are discussed.

Total Endoscopic or Endoscope-Assisted Excision of Non-embolized Advanced Juvenile Nasopharyngeal Angiofibroma: A Clinical Case Series.

Background Surgical excision is the primary treatment for juvenile nasopharyngeal angiofibroma (JNA), but this procedure is challenging due to its high vascularity and local aggressiveness. Moreover, preoperative embolization is a subject of debate. Objective The objective of this study is to assess the efficacy, safety, and feasibility of endoscope-assisted excision as a surgical intervention for non-embolized advanced JNA. Materials and methods This case series involved six male patients (mean age: 16 years) with JNA, classified as stages Ⅱc to Ⅲb according to the Radkowski classification. None underwent preoperative embolization. Results Two stage Ⅱc cases underwent total endoscopic endonasal excision. One patient with stage Ⅲa and another with stage Ⅲb underwent surgery via an endoscope-assisted sublabial approach. Two patients, one with stage Ⅱc JNA and another with Ⅲb, underwent a two-stage procedure. Postoperative CT scans showed no residual disease at the six-month mark. On average, each procedure required 1.5 units of blood transfusion. One patient experienced intraoperative bleeding, whereas the remaining patients were free of any major complications. The mean operation duration was 175 minutes per procedure. The mean length of stay at the hospital was 3.75 days per procedure. Conclusion Endoscope-assisted or purely endoscopic approaches can be safely and effectively employed for the complete excision of non-embolized advanced JNAs.

[Coblation-assisted endoscopic excision of juvenile nasopharyngeal angiofibroma and outcomes].

Objective:To summarize the procedures and efficacy of surgical treatment for Andrew stage Ⅰ-Ⅲ juvenile nasopharyngeal angiofibroma（JNA）. Methods:A total of 12 patients with JNA who underwent surgery from 2016 to 2021 were enrolled, including 1 case in stage Ⅰ, 3 cases in stage Ⅱ, and 8 cases in stage Ⅲ. JNA was resected by transnasal endoscopic approach alone, or combined with transoral approach or Caldwell-Luc approach was performed. Results:Eleven cases underwent complete resection without recurrence and 1 case had residual tumor. There were no serious complications. The median intraoperative blood loss was 200 mL, and 1 patient received blood transfusion. The median operative time was 110 minutes. Conclusion:JNA in Andrew stage Ⅰ-Ⅲ can be quickly and completely resected by standardized surgical procedures using endoscopy and coblation technology.