Multidisciplinary management of juvenile nasopharyngeal angiofibroma

Abstract

Background: Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign, but the locally aggressive, vascular tumor that occurs almost exclusively in young men. Although this tumor accounts for only about 0.5% of head and neck tumors, it is by far the most common benign nasopharyngeal neoplasm. It is presented typically with epistaxis, obstructive symptoms, and chronic otomastoiditis. The examination of this tumor reveals pale reddish-blue mass. The tumor is seen on imaging as vividly augmenting soft-tissue mass centered on the sphenopalatine foramen. The treatment of choice is usually surgical resection; either open or endoscopic. Pre-operative embolization is usually done to help with hemostasis. We aim to address the efficiency and the safety of endovascular modality in JNA. Methods: In the period between January 2012 to December 2017, 20 male patients with age ranging from 6 to 20 years were referred to the Endovascular Unit, at Departments of Neurosurgery in Sohag, Alexandria, and Tanta University Hospitals with JNF. Preoperative trans-arterial embolization was done, followed by endoscopic surgical resection by our ENT surgeons. All patients were subjected to clinical and radiological Imaging evaluation pre embolization, post embolization, and post endoscopic resection. All patients had clinical and radiological follow-ups for at least 1 year. Results: 20 male patients with JNA underwent preoperative super-selective trans-arterial embolization. The average age at presentation was 13 years. All patients underwent successful embolization with total obliteration of vascular blush of the tumor in 15 patients, and near-total obliteration of blush in 5 patients. The dramatic effect of preoperative embolization was observed on limiting intraoperative blood loss (average 200 ml) and decreasing the time of surgery (average 2.5 h). There was no permanent morbidity or mortality related to either embolization or endoscopic resection in all patients. Conclusions: Trans-arterial embolization is strongly recommended in patients with JNA, it offers a good assist to the surgeon, reduces blood loss, decreases the amount of transfusion, improves the degree of resection, reduces operative time, and decreases the incidence of recurrence.