Juvenile nasopharyngeal angiofibromas: A study of recurrence pattern and role of pre-Operative embolization - \'a decade\'S experience

JUVENILE N A S O P H A R Y N G E A L A N G I O F I B R O M A S : A STUDY OF R E C U R R E N C E PATTERN AND ROLE OF PRE-OPERATIVE EMBOLIZATION - 'A D E C A D E ' S EXPERI ENCE' A . M . S h e n o y 1, N. Grover z, Janardhan N. 3, J a y a k u m a r PN 4 , T. Hegde s, Satish S ~

Key Words :

Juvenile nasop.haryngeal angiofibroma, embolisation, tumor recurrence.

INTRODUCTION Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor seen in pre-pubertal and adolescent males often originating in the nasopharynx with a predilection to spread to different areas of skull base and adjacent recesses. The vascular nature of this tumor and the complex anatomical location often deters the surgeon from undertaking these resections lightly owing to the risks posed by difficult surgical exposure and rapid loss of blood, that make complete excision of JNA hazardous.

Review of literature reveals that average blood loss in preembolisation era, was 1136ml [1] With the advent of super selective embolization, the surgery for JNA has been revolutionized making it a less 'bloody -affair' and has greatly enhanced the complete surgical excision in an anatomic area hitherto referred to as ' difficult to access'. Good pre-operative radiological evaluation with high resolution CT scan and selection of appropriate soft tissue a p p r o a c h to access and e x p o s e the t u m o r in all its dimensions are the basic pre-requisite for a successful

~.2.3Department of Head and Neck Surgical Oncology, Kidwai Memorial Institute of Oncology,Bangalore,India. 4Department of lnterventional Neuro Radiology, National Institute of Mental Health and Neuro sciences, Bangalore,India?6Department of Neurosurgery, National Institute of Mental Health and Neuro sciences, Bangalore,lndia.

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Juvenile Nasopharyngeal Angiofibromas: A Stud.+' Of Recurrence Pattern And Role Of Pre-Operative Embolization ..

excision. There is a possibility of using a less mutilating surgical approach such as midfacial degloving and Le Fort Type 1 osteotomy should the tumor size and location permit it [ 2 ] .

Several authors are reporting the use of endoscopic excision for JNA limited to nose and pterygopalatine fossa [3,4] . All these limited access approaches have been justified because of the benign nature of a neoplasm located in a cosmetically 'sensitive' zone. Moreover in young prepubescent males surgical trauma to facial skeleton, may adversely impact tl]e midfacial growth in the future. However these attempts at 'surgical conservatism' should be utilised judiciously as residual tumor after inadequate excision may necessitate extensive skull base surgery at a later date with high morbidity. The morbidity of treating intracranial JNA with a high complication rate of 33% has been reported earlier [5] and warns against such 'limited access' at initial surgical forays without necessary expertise. In contrast, transfacial/midfacial degloving approaches for the limited lesion may be cosmetically acceptable with higher rate of complete and safe tumor excision; centers such as ours have therefore advocated lateral rhinotomy with or without lip split as a much preferred soft tissue approach while others have done away with facial incision recommending the mid-face degloving approach with LeFort type I osteotomy[2,6l . This approach has much to recommend in non recurrent midline lesions or lesions with unilateral extention to pterygopalatine fossa and/or anterior part of cavernous sinus. Follow up needs to be carried out every 3 months with a nasal endoscope in an area that has poor visibility with conventional office examination aids. A post excision CT scan at this time may highlight the presence of surgically inaccessible tumor as revealed by para- cavernous contrast enhancement or obvious tumor residua ; these patients can then be counseled about the benefits/risks from adjuvant radiotherapy and or treatment with androgen receptor antagonists [7,8]. Recently a French study [9], has advocated serial high resolution CT scan follow up which has revealed spontaneous regression of these putative remnants and stressed the need for surgical restraint, as long term follow-up has confirmed the asymptomatic nature of these residua.

M a t e r i a l s and M e t h o d s

This study is a retrospective analysis of 30 consecutive cases of JNA operated in the department of Head and Neck Surgery during the period 1996-2002. More than half of these (18) had a history of prior attempt at surgical removal. Postoperative histopathology confirmed the

Radkowski stage I A Tumor limited to posteriornares a n d / o r nasopharyngeal vault IB Tumor limited to posteriornares a n d / o r nasopharyngeal vault with involvement of at least one paranasal sinus II A Minimal lateral extention into pterygomaillary fossa IIB Full occupation of pterygomaxillary fossa with or without erosion of orbital bones II C Extention into infratemporal fossa or extention posterior to pterygoid plates I I I A Erosion of the base of skull -minimal intracranial extention III B Extensive intracranial ] extention with or without extention into cavernous sinus

Number of cases 2

Average Out come blood loss