Juvenile nasopharyngeal angiofibroma (JNA)

Considerations

• • Description 

    • well-vascularized tumor originating from the pterygopalatine fossa 

  • Anatomy 

    • pterygopalatine fossa

    • sphenopalatine foramen  

    • infratemporal fossa

    • orbit 

    • internal maxillary artery

    • sphenopalatine artery

    • infraorbital nerve 

  • Clinical picture 

    • adolescent male

    • epistaxis and/or nasal obstruction

  • Behavior

    • benign but locally invasive manner

  • Imaging 

    • MRI with IV contrast 

    • CT with IV contrast, image guidance protocol 

  • Staging 

    • Andrews staging system 

  • Treatment 

    • First line = Surgical resection

      • With or without pre-operative IR embolization

      • Approach

        • Classically open

        • Endoscopic is the current standard 

    • Primary or adjuvant radiation therapy is generally reserved for extensive lesions or recurrent tumors for which surgical intervention is precluded because of the high associated morbidity

  • Alternative treatment options include cryotherapy, chemotherapy, and hormonal manipulation

  • Exposure 

  • Margins 

Preparation

• • IV access and Blood products

    • Significant blood loss is expected

    • Two large bore IVs

    • Arterial line

    • Type and cross with pRBCs available

  • Equipment  

Procedure

Sample operative report

Post-op

Pearls & Pitfalls

High-Yield

Links

• • https://www.ncbi.nlm.nih.gov/pubmed/22269889

    • Coblation article 

  • https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Juvenile%20nasopharyngeal%20angiofibroma%20surgery.pdf

    • Operative technique 

  • http://www.american-rhinologic.org/videos_benign

    • Dissection videos

  • Timing of embolization 

    • https://www.ncbi.nlm.nih.gov/pubmed/12015840?access_num=12015840&link_type=MED&dopt=Abstract

    • http://jnis.bmj.com/content/early/2012/04/25/neurintsurg-2012-010350