Craniofacial approaches to large juvenile angiofibromas

Clinical article

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Object

Craniofacial approaches provide excellent exposure to lesions in the anterior and middle cranial fossae. The authors review their experience with craniofacial approaches for resection of large juvenile nasopharyngeal angiofibromas.

Methods

Between 1992 and 2009, 22 patients (all male, mean age 15 years, range 9–27 years) underwent 30 procedures. These cases were reviewed retrospectively.

Results

Gross-total resection of 17 (77%) of the 22 lesions was achieved. The average duration of hospitalization was 8.2 days (range 3–20 days). The rate of recurrence and/or progression was 4 (18%) of 22, with recurrences occurring a mean of 21 months after the first resection. All patients underwent preoperative embolization. Nine patients (41%) developed complications, the most common of which was CSF leakage (23%). The average follow-up was 27.7 months (range 2–144 months). The surgery-related mortality rate was 0%. Based on their mean preoperative (90) and postoperative (90) Karnofsky Performance Scale scores, 100% of patients improved or remained the same.

Conclusions

The authors' experience shows that craniofacial approaches provide an excellent avenue for the resection of large juvenile nasopharyngeal angiofibromas, with acceptable rates of morbidity and no deaths.

Abbreviation used in this paper: JNA = juvenile nasopharyngeal angiofibroma.

Article Information

Address correspondence to: Randall W. Porter, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013. email: neuropub@chw.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photomicrograph of an H & E–stained section of a JNA (original magnification × 40) showing that the tumor is composed of a bed of endothelial cell–lined vascular channels.

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    Preoperative axial (A) and coronal (B) MR images showing the tumor extension into the cranial cavity. Angiogram (C) obtained after Onyx embolization showing the highly vascular nature of these lesions.

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    A: Drawing showing domains in the anterior skull base and clivus that can be exposed by the direct anterior craniofacial route used in this paper. B: Drawing showing the combination of a modified transbasal (red region) and a transmaxillary (blue region) approach providing exposure to the entire midline skull base. The transmaxillary approach can be done in 2 ways (dotted and solid lines). Modified from art published in and reprinted with permission from Beals SP, Joganic EF: Transfacial approaches to the craniovertebral junction, in Dickman CA, Spetzler RF, Sonntag VKH (eds): Surgery of the Craniovertebral Junction. New York: Thieme, 1998, pp 395–418. C: The combination of the 2 approaches is illustrated, with preservation of the cribriform plate depicting the depth of exposure. Reprinted from Beals SP, Joganic EF, Hamilton MG, et al: Posterior skull base transfacial approaches. Clin Plast Surg 22:491–511, 1995. Used with permission from Barrow Neurological Institute.

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    Upper: Intraoperative photograph showing an upper incision of the buccal sulcus to expose the anterior maxilla. Lower: If palatal splitting is required, the midline is incised through the oral mucosa and the soft palate on one side of the uvula. Reprinted from Beals SP, Joganic EF, Hamilton MG, et al: Posterior skull base transfacial approaches. Clin Plast Surg 22:491–511, 1995. Used with permission from Barrow Neurological Institute.

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    Postoperative axial (left) and coronal (right) MR imaging studies confirming gross-total resection of the lesion.

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