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Juvenile nasopharyngeal angiofibroma resection: Novel technique to improve posterior/inferior margin control
Author(s) -
Kamat Ameet,
Goldstein Gregg H.,
Kennedy David W.
Publication year - 2014
Publication title -
the laryngoscope
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.181
H-Index - 148
eISSN - 1531-4995
pISSN - 0023-852X
DOI - 10.1002/lary.24391
Subject(s) - margin (machine learning) , resection , juvenile nasopharyngeal angiofibroma , control (management) , computer science , content (measure theory) , juvenile , psychology , artificial intelligence , medicine , surgery , biology , mathematics , machine learning , genetics , mathematical analysis
Juvenile angiofibroma (JNA) is a benign neoplasm that accounts for <0.5% of all head and neck tumors. JNAs typically present in adolescent male patients with recurrent frequent epistaxis and unilateral nasal obstruction. Although histologically benign, the tumor’s immense vascularity and propensity for local invasion make resection technically challenging. With the increased utilization of angiography and embolization coupled with the rapid advancement of endoscopic skull base techniques, traditional transfacial open approaches have progressed to extended endoscopic endonasal approaches for JNA resection. With proper patient selection, several authors have shown that endoscopic approaches can offer decreased operative time and blood loss with enhanced visualization through magnified and multiangle views. Regardless of the approach, the procedure is still complicated by lesion vascularity, with an average intraoperative blood loss of >650 mL. Bleeding and the subsequent increased length of surgery may hamper a surgeon’s ability to maintain accurate oncologic resection, increasing the risk for recurrence. JNAs are usually well demarcated laterally and inferiorly, but posteriorly, the tumor frequently extends into the vidian canal and tends to fuse with the buccopharyngeal fascia in the roof of the nasopharynx. It is the senior author’s experience that identifying this posterior and inferior margin within the nasopharynx at the end of the surgical procedure may be difficult due to several factors, including poor visualization in a bloody surgical field. Whereas typically the first step in JNA surgery is identification and ligation of the internal maxillary artery, the goal of this report is to present an alternative approach whereby the initial surgical step is to identify, demarcate, and separate the posterior margin of the tumor from the adjacent mucoperiosteum and fascia within the nasopharynx. Performing this step under transoral endoscopic visualization at the beginning of the procedure provides a more accurate perspective of the posterior margin and markedly reduces the difficulty of identifying and resecting this part of the tumor. We hope that by adding this novel surgical technique to our endoscopic armamentarium, we may be able to decrease the risk of tumor recurrence.