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Angiofibroma
Evaluation and Treatment
Viet Pham, MD
Shraddha Mukerji, MD
The University of Texas Medical Branch (UTMB Health)
Department of Otolaryngology
Grand Rounds Presentation
December 29, 2012
In 5th century BC
Description with nasal polyps
Chelius, 1847
Fibrous nasal polyp
Association with puberty
“Angiofibroma” coined in 1940
by Friedberg (Gullane 1992)
(Hauptman 2007)
JNA
Demographics
Arterial supply
Internal maxillary most common
Other sources
Ascending pharyngeal
External carotid
Internal carotid
Common carotid
Occasional
contralateral supply
Controversal origin
Posterolateral nasal wall at sphenopalatine
foramen
Vidian canal
Embryologic chondrocartilage of skull
bones (Schiff 1959)
Superior margin of sphenopalatine foramen
Trifurcation (Neel 1973, Bremer 1986)
Palatine bone
Horizontal ala of vomer
Root of pterygoid process
Myofibroblast origin
Fibrous pseudocapsule
Multiple vascular channels
Abundant endothelium lining
Collagenous tissue network (Hauptman 2007)
Adolescent male
Unilateral nasal obstruction most common
Recurrent epistaxis
Nasal mass
Smooth, lobulated
Compressible
Purplish or reddish hue
(Hauptman 2007)
JNA
Atypical Presentation
Uncommon Advanced
Middle ear effusion Facial swelling/mass
Dacrocystitis Proptosis
Rhinolalia Cranial neuropathy
Palate deformity Headaches
Hyposmia or Massive hemorrhage
anosmia
Bilateral (Rha 2003)
Sphenopalatine Nasal
Nasopharynx Foramen cavity
Pterygopalatine Sphenoid
Fossa Sinus
Masticator
Orbit Space
(Operative Techniques in Otolaryngology
1999; 10(2): 101-106.)
Previous systems
1981 - Sessions
1983 - Fisch
1984 - Chandler
(Douglas 2006)
1989 - Andrews
Radkowski most recent, 1996
Posterior extension to pterygoid
plates
Degree of skull base erosion
None is universally accepted
STAGE FEATURES
STAGE FEATURES
STAGE FEATURES
STAGE FEATURES
(Liu 2002)
Radiology
CT
(John 2006)
Radiology
MRI
(Umamaheswar 2006)
Angiography
Preoperative Embolization
Moulin, 1995
Embolized 7 of 20 patients
Less intraoperative hemorrhage,
1037.5mL vs 5380mL
Statistically significant for high-
grade tumors only
Li, 1998
Embolized 11 of 21 patients
Less intraoperative hemorrhage,
677mL vs 1136mL
Less transfusion, 400mL vs 836mL
(Moulin 1995)
Angiography
Preoperative Embolization
Liu, 2002
Embolized 13 of 34 patients between 1986-1999
External carotid ligation in 9
No preoperative treatment in 12
Less intraoperative hemorrhage with
embolization
275mL vs 840mL
Tumors limited to nasal cavity or nasopharynx
No hemorrhage difference
Larger tumors
No difference compared with carotid ligation
Tumor hypoxia may cause radioresistance
(Amdur 2011)
(Liu 2002)
JNA
Treatment
Surgery
Radiation (XRT)
Chemotherapy
Hormone therapy
Other
Treatment
Surgery
Transpalatal
Lateral Rhinotomy
Midfacial degloving
Infratemporal fossa and
craniotomy
Endoscopic transnasal
Surgery
Transpalatal
Facial translocation
Intercartilaginous and transfixion nasal incisions
Gingivobuccal incision
Le Fort I osteotomies
Nasal crusting
Epistaxis
Nasolacrimal duct
obstruction
Facial paresthesia
Facial palsy (Operative Techniques in Otolaryngology 2001; 12(4):214-218.)
Oroantral fistula
Vestibular stenosis
Carotid artery rupture
(Radkowski 1996)
Surgery
Infratemporal Fossa and Craniotomy
Middle turbinectomy as
needed for exposure
Middle meatus antrostomy
Resect posterior maxillary
wall
Sphenopalatine artery
ligation
Tumor resection from
pterygopalatine fossa
(Wormald 2003)
Surgery
Endoscopic Complications
Nasal synechia
Cheek paresthesia
Lacrimal duct stenosis
Vision changes
Diplopia
Damage to cranial nerves,
III and IV
Sphenoid mucocele
Cavernous sinus injury
(Wormald 2003)
Surgery
Endoscopic Complications
Superior orbital Posterior maxillary
fissure sinus wall
Middle turbinate
Nasal
remnant synechia
Greater Descending
palatine nerve palatine artery
Pterygoid fossa
Clivus
Basisphenoid
Sphenoid diploe
Cavernous sinus
Intracranial
Lateral rhinotomy and midfacial degloving
Wide access
Cosmetic deformity
Surgery
Planning Approach
(Hazarika 2002)
Conclusion
Rare vascular neoplasm
Adolescent males
Posterolateral nasopharynx
Nasal obstruction and
epistaxis
Surgery is mainstay of
treatment
Radiation is feasible
alternative
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