Juvenile Angiofibroma: The “Anchorage” Concept

Abstract

Objective: To present the Anchorage Concept, a set of characteristics shown by juvenile nasopharyngeal angiofibroma (JNA) that hinder the surgical resection and contribute to intraoperative complications and incomplete excisions. Method: Case series consisting of 46 JNAs in the past 10 years (2001-2011) and including tumors I to IIIb in Radowski staging classification. Surgical technique varied according to tumor stage and included exclusive endoscopic surgery, external access and combined, with or without preoperative embolization. Results: Multiplicity of vascular pedicles: The maxillary artery, JNA's principal irrigation source, commonly presents as an extension of the lesion, laterally positioned. This characteristic makes vascular clipping difficult and demands a careful surgical dissection next to the external carotid vascular trunk. Besides its main vascular trunk, JNA has many other vascular pedicles which become an anchoring factor and provoke intraoperative bleeding. Vector and growth angles: During its growth, JNA may dispose vectors that form angles in relation to nasal cavity. Sometimes, these angles are 90degree shaped. From its origin at the upper margin of the sphenopalatine foramen, JNA grows forward and backward into the nasal cavity and maxillary sinus, upward into the sphenoid, laterally toward the pterygopalatine fossa, and inferiorly toward the infratemporal fossa, via the pterygomaxillary fissure. Conclusion: The Anchorage Concept must be taken into account in the management of JNA. Knowledge of these points is of great value to facilitate the removal of the tumor, which persists being a surgical challenge in most cases.