Juvenile nasopharyngeal angiofibroma: analysis of 42 cases and important aspects of endoscopic approach.

OBJECTIVE: To determine the general characteristics of 42 patients who were operated for juvenile nasopharyngeal angiofibroma (JNA); and to determine the important aspects and the advantages of endoscopic transnasal approach over other techniques.
METHODS: Forty-two patients with JNA, 12 of whom were operated with endoscopic transnasal approach at a tertiary care center between March 1987 and February 2008 were evaluated retrospectively. The general characteristics of the patients, presenting signs and symptoms, the surgical approach performed, tumor stage, whether preoperative embolization was performed and rates of recurrence were studied. Patients who underwent surgery with endoscopic transnasal approach were compared to others who underwent surgery with different techniques.
RESULTS: One patient was female and the remaining 41 patients were male. Twelve patients underwent endoscopic removal of the tumor. Lateral rhinotomy was used for 10 patients, degloving approach for 7 patients, transpalatal approach for 6 patients, combined approach for another 6 patients and finally midfacial splitting for 1 patient. Seventeen percent of the patients had referred with recurrent diseases. According to staging system of Radkowski, about half of the patients belonged to stage IIA or IIC. The mean age was 16 and the most common presenting symptom was nasal obstruction. Preoperative embolization rate was 59.5% while recurrence rate in the postoperative period was 17%. In non-endoscopic approaches, the tumor contiguity and operative plan were determined via radiological data. In operations performed with endoscopic transnasal approach in patients with JNA, the radiological data as well as a detailed endoscopic tumor examination were utilized and it was observed that tumor invaded the middle turbinate in 67% and both the septum and middle turbinate in 42% of the patients. While preoperative embolization was performed only in larger tumors before 1998, it was recruited in all subjects after 1998. Preoperative and postoperative hemorrhage were less, and durations of packing and hospitalization were shorter in patients operated with endoscopic approach plus preoperative embolization.
CONCLUSION: Endoscopic transnasal approach has advantages of no non-cosmetic sequela, less hemorrhage and no disruption in facial skeleton. Besides, this method allows better visualization of tumor contiguity and enables dissection and ligature of vascular structures in JNA surgery. The rate of tumors associated with middle turbinate and septum is greater than that is assumed in patients with JNA. Starting the tumor excision with partial resection of the middle turbinate and subperiostal dissection of the septum and anterior sphenoidal wall, and avoiding direct contact with the tumor might decrease the amount of bleeding.