Outcomes of a Modern Treatment Approach: Endoscopic Endonasal and Transmaxillary Resection for Advanced Juvenile Nasopharyngeal Angiofibroma

Introduction: Advanced juvenile nasopharyngeal angiofibroma (JNA) has historically been resected via open transfacial and transcranial approaches. Recently, endoscopic endonasal/transmaxillary surgery (EE +TMS) has emerged as a safe and effective alternative.

Objective: This article aims to report our experience treating JNA with EE+TMS at a single large pediatric tertiary referral center.

Materials and Methods: This study is a retrospective review of patients treated with EE+TMS for JNA between 2009 and 2022. Advanced stage was defined as UPMC stage III, IV, or V.

Results: Twenty-six patients were included. All were male with a median age of 14.1 years (range: 7.5–16.7). Most tumors were UPMC stage V (n = 21, 81%) with lesser proportions of stage III (n = 3, 11%) and IV (n = 2, 8%). Median tumor volume was 67 cm³ (range 5.2–250). Despite a majority of tumors with significant intracranial extension (n = 21, 81%), infratemporal fossa (n = 24, 96%), cavernous sinus (n = 19, 76%), and orbit (n = 15, 60%), all were successfully resected primarily with EE + TMS. The anterior transmaxillary corridor was used for lateral extension into the infratemporal fossa (n = 17, 65%). Two cases (7%) required lateral orbitotomy and one subtemporal craniotomy (4%) for complete resection of medial sphenoid wing tumor. The rate of gross total resection was 80% (n = 20). Preoperative embolization was performed for all patients (n = 26, 100%). Despite embolization, median blood loss was 1.5 L (range: 750 mL–16 L). Six patients (23%) required staged resection due to blood loss. Most tumors (n = 23, 88% of 26) had residual vascular supply from multiple feeding vessels including directly from the internal carotid (ICA) (n = 19, 82% of 23), internal maxillary artery (n = 4, 17% of 23) and ophthalmic arteries (n = 2, 9% of 23). Postoperative complications included an embolization-related stroke (n = 1, 5%), complete monocular blindness due to central retinal artery occlusion (n = 1, 5%), and ICA injury requiring vessel sacrifice (n = 1, 5%) without consequence. Seven patients (27%) suffered recurrence at a median of 10 months postoperatively (range: 5–33). Five recurrences were completely resected via EETS, but two in the medial sphenoid wing (28% of 7) required addition of lateral orbitotomy.

Conclusion: EETS is safe and effective for resection of all JNAs in children. It offers excellent exposure even in large tumors with lateral or intracranial extension. In rare cases of disease with sphenoid wing extension, addition of lateral orbitotomy can facilitate complete resection.

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Artikel online veröffentlicht:
07. Februar 2025