gms | German Medical Science

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge
7th Congress of the European Skull Base Society held in association with
the 13th Congress of the German Society of Skull Base Surgery

18. - 21.05.2005, Fulda, Germany

Endoscopic resection of juvenile angiofibromas – long term results

Meeting Contribution

  • T. Alborno - Department of ORL Head & Neck Surgery, University Medical School Graz, Graz, Austria
  • T. Hofmann - Department of ORL Head & Neck Surgery, University Medical School Graz, Graz, Austria
  • A. Lackner - Department of ORL Head & Neck Surgery, University Medical School Graz, Graz, Austria
  • H. Stammberger - Department of ORL Head & Neck Surgery, University Medical School Graz, Graz, Austria
  • W. Koele - Department of ORL Head & Neck Surgery, University Medical School Graz, Graz, Austria
  • P. Reittner - Department of Radiology, University Medical School Graz, Graz, Austria
  • E. Klein - Department of Radiology, University Medical School Graz, Graz, Austria

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge. 7th Congress of the European Skull Base Society held in association with the 13th Congress of the German Society of Skull Base Surgery. Fulda, 18.-21.05.2005. Düsseldorf: German Medical Science GMS Publishing House; 2009. Doc05esbs09

DOI: 10.3205/05esbs09, URN: urn:nbn:de:0183-05esbs099

Published: January 27, 2009

© 2009 Alborno et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Outline

Text

Introduction

Juvenile nasopharyngeal angiofibromas (JNA) are highly vascularized benign lesions that typically occur in male adolescents complaining of nasal obstruction and epistaxis [1]. Therapy is often challenging due to tumor spread into critical areas such as pterygopalatine and infratemporal fossa, skull base, orbit or even intracranially. Cranial nerves, carotid arteries, cavernous sinus and dura can be infiltrated. Although spontaneous regression of the tumor has been reported [2], surgical resection is considered as therapy of choice. Surgical procedures include transpalatal techniques, lateral rhinotomy, midfacial degloving, infratemporal approaches and combined infratemporal and frontotempral techniques [3], [4].

Methods and results

We present a retrospective study of the charts of ten patients undergoing endonasal endoscopic surgery for JNA between 1994 and 2002 (Table 1 [Tab. 1]). Setting was the Department of ORL, University Medical School of Graz, Austria. All patients were male, between 13 and 24 years of age. According to Andrews/Fisch the tumors of this series were classified from II to IIIa. All patients underwent angiography and embolization of the tumor feeding vessels 1 to 20 days preoperatively. Two tumors with feeding branches from the internal carotid artery could not be fully embolized. In all patients a combined endonasal and enoral endoscopic tumor resection was performed. For three resections of type IIIa angiofibromas an intraoperative computer assisted guiding system was applied (ENTrak, GE Medical, Lawrence, USA). Two of 10 patients (20%) had recurrences requiring further treatment. One of these could be managed successfully with a second endoscopic resection 23 months after first surgery. The other due to embolisation complications was not operated upon, but underwent gamma knife therapy. No peri- or postoperative complication was observed. No blood transfusions were required in any of the 10 cases. Eight patients (80%) at follow up were free of symptoms and showed a normal postoperative cavity with nasal endoscopy. Two of these patients and the patient, who underwent revision surgery demonstrated minor signal enhancement on postoperative MRI, which we classified as supposedly minimal residual disease. MRI follow up showed no growth and patients were free of symptoms without further treatment at 38, 61 and 108 months postoperatively. The overall cure rate including one patient undergoing a second endoscopic resection and three patients with non growing minimal residual tumor tissue was 90%. Postoperative follow up including nasal endoscopy and Magnetic Resonance Imaging (MRI) ranged from 5 months to nine years, mean follow up was 39.1 months.

Discussion

Transfacial approaches like midfacial degloving or lateral rhinotomy are considered standard techniques for resection of juvenile angiofibromas with tumor extension to the nasopharynx, pterygopalatine fossa, sphenoid, and skull base. Fisch [3] recommends his type C infratemporal approach for type III and IV juvenile angiofibromas. These techniques enable optimal tumor exposure, but side effects cannot be excluded in any case. Hypesthesia of V2 and V3, serous otitis media and transient trismus were described after infratemporal approaches [5]. First reports about successful endoscopic resections of JNAs have been published since 1998 [6], [7]. Draf et al. [8] successfully resected JNAs type I-II with an endonasal microendoscopic approach. Type IV JNA however, pose a clear limitation to exclusively endoscopic approaches, as do some forms of orbital fissure involvement. The risk for recurrence is higher if tumor involvement of the base of pterygoids, deep invasion of the sphenoid, cavernous sinus or infratemporal fossa is present [4]. The low morbidity, short hospitalization and minimal invasive character of the endoscopic approach have clear advantages. Endonasal endoscopic resections of JNA have been performed in our department since 1994. Therefore we are now able to present long-term results of a case series of ten consecutive patients up to nine years. Patients were operated by the same surgeon and followed up endoscopically and via MRI. The present series includes four type IIIa tumors with involvement of the infratemporal fossa. In all cases an exclusively endoscopic tumor removal via a combined endonasal and enoral approach was possible. Extension to the medial aspect of the infratemporal fossa and retromaxillary space was no contraindication for an endoscopic approach.

Conclusion

Endoscopic resection of nasopharyngeal angiofibromas up to stage IIIa according to Fisch can be recommended for experienced endoscopic surgeons. Advantages of the endoscopic technique are the minimal invasive character and low morbidity. The intraoperative computer assisted guiding system helps to orientate, but will never replace the surgeon’s detailed knowledge of this complicated anatomical area.


References

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