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Intranasal endoscopic excision of a juvenile angiofibroma1
Auris Nasus Larynx 25 (1998) 39 – 44
Intranasal endoscopic excision of a juvenile angiofibroma1 Mary T. Mitskavich, Ricardo L. Carrau *, Carl H. Snyderman, Jane L. Weissman, Johannes J. Fagan Uni6ersity of Pittsburgh School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Department of Radiology, Eye and Ear Institute, 203 Lothrop Street, Suite 500, Pittsburgh PA 15213, USA Received 26 February 1997; accepted 30 May 1997
Abstract Intranasal endoscopic excision of a juvenile nasopharyngeal angiofibroma (JNA) was performed in a 13 year old white male. The patient remains disease-free 24 months after the operation. Although endoscopic surgical techniques have been applied to the therapy of some benign nasal tumors, such as inverting papilloma, endoscopic resection of a documented JNA has not been previously reported. This technique is reserved for tumors which are limited to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa. © 1998 Elsevier Science Ireland Ltd. Keywords: Angiofibroma; Technique; Nasopharyngeal neoplasm
1. Introduction Juvenile nasopharyngeal angiofibroma (JNA) is a benign, highly vascular tumor that predominantly affects adolescent males. The histologically benign appearance is often countered by a potentially aggressive clinical course. The advent of computerized tomographic (CT) scanning, selec* Corresponding author. Tel.: + 1 412 6472110; fax: +1 412 6472080. 1 Presented at the American Rhinologic Society at the Combined Otolaryngologic Spring Meeting, Orlando, FL, May 6, 1996.
tive angiography with embolization and refinements in surgical approaches have allowed better preoperative planning and an attendant reduction in morbidity and mortality [1]. Topographic localization, tumor extension and the experience of the surgical team dictate the approach. Commonly used options for surgical access include the transpalatal, Lefort I maxillotomy, medial maxillectomy, facial translocation, or infratemporal fossa approaches. We employed an intranasal endoscopic technique for resection of a JNA which was limited to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa.
0385-8146/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 8 5 - 8 1 4 6 ( 9 7 ) 1 0 0 0 6 - 2
40
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
2. Case report A 13 year old white male presented to the emergency room with a 2 year history of intermittent right-sided epistaxis and nasal congestion. Intranasal endoscopic examination revealed a smooth, polypoid mass filling the posterior nasal cavity and extending medially and inferiorly to the posterior third of the middle turbinate (Fig. 1). The remainder of the physical examination was normal. Bleeding was controlled using a hemostatic nasal sponge. Axial and coronal CT images obtained with intravenous contrast showed a mass filling the right posterior nasal cavity extending from the nasopharynx into the pterygopalatine fossa (Fig. 2). External carotid arteriography demonstrated an intensely vascular mass supplied by the distal internal maxillary artery (Fig. 3). The distal internal maxillary and ascending pharyngeal arteries were embolized with polyvinyl alcohol and microcoils. Contrast injection after embolization
Fig. 1. Smooth polypoid mass (T) filling the posterior nasal cavity and extending medially and inferiorly to the middle turbinate (M), extending inferiorly to the level of the inferior turbinate (I).
Fig. 2. Axial contrast enhanced CT scan shows a mass in the right posterior nasal cavity (T). The mass extends through the posterior choana into the nasopharynx and through the sphenopalatine foramen into the pterygopalatine fossa.
demonstrated marked reduction in the vascularity of the mass. The patient was taken to the operating room within 24 h of embolization. The packing was removed, and 0.05% oxymetazoline soaked pledgets were placed intranasally. Under endoscopic control, the septum, the base of the angiofibroma and the middle and inferior turbinates were
Fig. 3. Lateral view of an external carotid injection shows a large, enhancing mass supplied by the internal maxillary artery.
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
infiltrated with 1% xylocaine with epinephrine 1:100 000. The base of the JNA along the postero-lateral nasal wall and the roof of the nasal cavity was dissected using bipolar electrocautery. In order to improve visualization, the tumor was debulked and the margins were reexcised using blunt dissection and bipolar electrocautery. Tumor erosion of the face of the sphenoid sinus, which was noted on the preoperative CT scan, was confirmed intraoperatively. Next, the portion of the tumor extending into the pterygopalatine fossa (PPF) was addressed. The middle turbinate was lateralized and mucosa covering the posterior aspect of the maxillary sinus was elevated. Bone was removed from the posterior wall of the maxillary sinus and the sphenopalatine artery cauterized. After complete tumor removal, the nose was then packed with a nasal tampon. Total time in the operating room was 3 h and blood loss was approximately 100 cm3. The patient did well postoperatively and was discharged the following day. The packing was removed 3 days later. Microscopic pathology was consistent with JNA. Two months postoperatively, follow up endoscopic examination revealed an erythematous mass in the region of the sphenopalatine foremen. CT demonstrated minimal abnormal soft tissue along the posterior roof of the right nasal cavity which was felt to be residual tumor or scar (Fig. 4). To rule out recurrence, intraoperative biopsy of the mass was elected. Using endoscopic visualization, the periphery of the lesion was cauterized and the mass bluntly elevated. Further bone removal of the posterior wall of the maxillary sinus allowed wide exposure of the PPF. The pedicle of the dissected specimen was then cauterized and removed. A small amount of persistent bleeding in the PPF was controlled with Oxycel and a hemostatic sponge. The patient was discharged the following day and the packing was removed 3 days later in the office. Pathologic analysis revealed scar tissue with no evidence of residual angiofibroma. The patient remains disease free 25 months later (Fig. 5).
41
Fig. 4. Follow-up coronal CT scan shows only a small amount of soft tissue along the roof of the right nasal cavity. This could represent residual tumor or scar.
3. Discussion JNA is a rare benign tumor of unclear etiology found in adolescent and young adult males. Growth begins postero-laterally at the superior margin of the sphenopalatine foramen. This area forms the junction of the sphenoidal process of the palatine bone and the pterygoid process of the sphenoid bone. Growth can subsequently occur anteriorly into the nasal cavity, superiorly into the sphenoid or sella, or laterally through the
Fig. 5. 13 month follow-up with cavity free of disease.
42
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
Table 1 Surgical approaches for nasopharyngeal Tumor extension
Nasopharynx Nasal cavity Ethmoids Sphenoid sinus Pterygopalatine fossa Medial infratemporal fossa Medial cavernous sinus Lateral infratemporal fossa Medial cavernous sinus Lateral cavernous sinus Middle cranial fossa
Surgical approaches ESS
T-palate
Le Forte 1
M-Max
ITF
TX facial
Facial TX
x x x x
x x
x x x x x x x
x x x x x x x
x
x
x
x x x x x x x x x x x
x x x x x x x x x x x
x
x x x x x x x
Adapted from [12]. ESS, endoscopic; T-palate, transpalatal; M-Max, medial maxillectomy; IT, infratemporal fossa; TX facial, transfacial; Facial TX, facial translocation.
sphenopalatine foramen into the PPF. The lesion can also continue to expand further laterally via the pterygomaxillary fissure into the infratemporal fossa. Several routes of intracranial extension have been identified: (1) From the infratemporal fossa through the floor of the middle cranial fossa; (2) from the pterygomaxillary fissure along foramen rotundum into the cavernous sinus; (3) from the sphenoid sinus via the superior wall into the cavernous sinus and/or pituitary fossa [2]; and (4) from PPF through vidian canal. Different staging systems have been proposed for JNA, but are rarely useful prospectively because most institutions have not adopted any single staging system [3–8]. Surgical resection is the therapeutic modality of choice for most extracranial JNA. Refinement of surgical techniques, coupled with improved preoperative planning, utilizing CT scanning and angiography with embolization, have decreased the morbidity and mortality of resection. The role of radiation therapy has been reserved for patients refusing surgery, those with surgically inaccessible intracranial extensions of tumor and those with significant medical contraindications to surgical intervention. Goepfert et al. [9] reported five cases of angiofibroma successfully treated with chemotherapy. Chemotherapy is recommended
for treatment of recurrent lesions not amenable to surgery or radiation. Although spontaneous regression after puberty has been suggested, the evidence for this is scanty; to date only two documented cases exist in the English language literature [10,11]. The surgical approach is dictated by the topographic localization and extent of the tumor as well as the experience of the surgical team. Table 1 shows the options for surgical access according to tumor location [12]. Included is the intranasal endoscopic approach which will allow excision of tumors confined to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa. The advantages of the intranasal endoscopic technique are minimal soft tissue and bone trauma, improved cosmesis and patient comfort and shortened hospital stay. The avoidance of extensive soft tissue and bone disruption lessens the potential impact on craniofacial growth. Several studies have examined the effect of craniofacial surgery on the development of the facial bones. Although the detailed findings of experimental animal models are not necessarily applicable to humans, certain general principles have been established. Dissection of soft tissue from the facial bones may restrict facial growth and
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
facial osteotomies may lead to growth retardation [13–20]. Metal plating of the cranial vault or across suture lines has been shown to restrict local bone growth [13,16,21,22]. Normal facial bone development is dependent on normally functioning facial and masticatory muscles and normal trigeminal and facial nerve function [18,19,23]. Disadvantages of the endoscopic approach include limited access, tedious and piece-meal dissection and limited visibility due to bleeding and tumor bulk. The skill and judgement of the endoscopic surgeons are vitally important and the surgeon must be familiar with alternative approaches. Close follow-up after endoscopic excision is required. Batsakis [24] reported that symptomatic recurrences occur during the first 12 months after primary treatment and are unusual after 2 years. The endoscope is a valuable adjunct to serial radiologic examinations for the early detection of recurrent disease. The ready availability of rigid endoscopes in office practice should aid in the diagnosis of JNA at an earlier stage, allowing for endoscopic excision. Only the experienced endoscopist, cognizant of the advantages and limitations of the endoscopic approach, should attempt this form of intervention. Further experience and longterm follow up is required. The use of the rigid endoscope to supplement standard techniques is also being explored.
References [1] McCary WS, Gross CW, Reibel JF, Cantrell RW. Preliminary report: Endoscopic versus external surgery in the management of inverting papilloma. Laryngoscope 1994;104:415 – 9. [2] Neel HB, Whicker JH, Devine KD. Juvenile anglofibroma-a review of 120 cases. Am J Surg 1973;126:547– 60. [3] Sessions RB, Bryan R, Naclerio R, Alford B. Radiographic staging of juvenile angiofibroma. Head Neck Surg 1981;3:279 – 83. [4] Tandon DA, Bahadur S, Kacker SK, Goulatia RK. Nasopharyngeal angiofibroma: A nine year experience. J Laryngol Otol 1988;102:805–9.
43
[5] Antonelli AR, Cappeillo J, Dilorenzo D, Donajo CA, Nicolai P, Orlandini A. Diagnosis, staging, and treatment of juvenile nasopharyngeal angiofibroma. Laryngoscope 1987;97:1319 – 25. [6] Chandler JR, Goulding R, Moskowitz L, Quencher R. Nasopharyngeal angiofibroma: Staging and management. Ann Otol Rhinol Laryngol 1984;93:322 – 9. [7] Mishra SC, Shukla GK, Bhatia N, Pant MC. A rational classification of angiofibromas of the post nasal space. J Laryngol Otol 1989;103:912 – 6. [8] Andrews JC, Fisch U, Valavanis A, Aeppli U, Makek MS. The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach. Laryngoscope 1989;99:429 – 37. [9] Goepfert H, Cangir A, Lee YY. Chemotherapy for aggressive juvenile angiofibromas. Laryngoscope 1985;111:285 – 9. [10] Jacobsson M, Petruson B, Ruth M, Svendson P. Involution of juvenile nasopharyngeal angiofibroma with intracranial extension. Arch Otolaryngol Head Neck Surg 1989;115:238 – 9. [11] Weprin LS, Seimers PT. Spontaneous regression of juvenile nasopharyngeal angiofibroma. Arch Otlaryngol Head Neck Surg 1991;117:796 – 9. [12] Fagan JJ, Snyderman CH, Carrau RL, Janecka IP. Nasopharyngeal angiofibromas-selecting a surgical approach. Head Neck 1997;391 – 7. [13] Batsakis JG. Tumors of the head and neck: Clinical and pathological considerations. 2nd edn. Baltimore: Williams and Wilkins, 1979. [14] Laurenzo JF, Canady JW, Zimmerman MB, Smith JH. Craniofacial growth in rabbits: Effects of midfacial surgical trauma and rigid plate fixation. Arch Otolaryngol Head Neck Surg 1995;1221:556– 61. [15] Freihofer HPM. The timing of facial osteotomies in children and adolescents. Clin Plast Surg 1982;9:445 – 56. [16] Shapiro PA, Kokich VG, Hohl TH. The effects of early Le Fort I osteotomies on the craniofacial growth of juvenile Macaca nemestrina monkeys. Am J Orthod 1981;79:492 – 9. [17] Wong L, Dufesne CR, Richtsmeier JT, Manson PN. The effect of rigid fixation on growth of the neurocranium. Plast Reconstr Surg 1991;88:395 – 403. [18] Ousterhout DK, Vargervik K. Maxillary hypoplasia secondary to midfacial trauma in childhood. Plast Reconstr Surg 1987;80:491 – 7. [19] Del Campo AF, Elizondo MM, Magnelli LM, Valadez AS, Ontiveros DS. Craniofacial development in rats with early resection on the zygomatic arch. Plast Reconstr Surg 1995;95:486 – 95. [20] Jacobs B, Kronman JH. The zygomatic arch and its possible influence on craniofacial growth and development. Angle Orthod 1977;47:136 – 40. [21] Nandra R, Sugawara J, Topazian RG. Effect of maxillary osteotomy on subsequent craniofacial growth in adolescent monkeys. Am J Orthod 1983;83:391 – 407.
44
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
[22] Eppley BL, Platis JM, Sadove AM. Experimental effects of bone plating in infancy on the craniomaxillofacial skeletal growth. Cleft Palate-Craniofac J 1993;30:164–9. [23] Lin KY, Bartlett SP, Yaremchuk MJ, Grossman RF, Upupa JK, Whitaker LA. An experimental study on the
effect of rigid fixation on the developing craniofacial skeleton. Plast Reconstr Surg 1991;87:229 – 35. [24] Behrents RG, Johnston LE. The influence of the trigeminal nerve on facial growth and development. Am J Orthod 1984;85:199 – 206.
.
Intranasal endoscopic excision of a juvenile angiofibroma1 Mary T. Mitskavich, Ricardo L. Carrau *, Carl H. Snyderman, Jane L. Weissman, Johannes J. Fagan Uni6ersity of Pittsburgh School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Department of Radiology, Eye and Ear Institute, 203 Lothrop Street, Suite 500, Pittsburgh PA 15213, USA Received 26 February 1997; accepted 30 May 1997
Abstract Intranasal endoscopic excision of a juvenile nasopharyngeal angiofibroma (JNA) was performed in a 13 year old white male. The patient remains disease-free 24 months after the operation. Although endoscopic surgical techniques have been applied to the therapy of some benign nasal tumors, such as inverting papilloma, endoscopic resection of a documented JNA has not been previously reported. This technique is reserved for tumors which are limited to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa. © 1998 Elsevier Science Ireland Ltd. Keywords: Angiofibroma; Technique; Nasopharyngeal neoplasm
1. Introduction Juvenile nasopharyngeal angiofibroma (JNA) is a benign, highly vascular tumor that predominantly affects adolescent males. The histologically benign appearance is often countered by a potentially aggressive clinical course. The advent of computerized tomographic (CT) scanning, selec* Corresponding author. Tel.: + 1 412 6472110; fax: +1 412 6472080. 1 Presented at the American Rhinologic Society at the Combined Otolaryngologic Spring Meeting, Orlando, FL, May 6, 1996.
tive angiography with embolization and refinements in surgical approaches have allowed better preoperative planning and an attendant reduction in morbidity and mortality [1]. Topographic localization, tumor extension and the experience of the surgical team dictate the approach. Commonly used options for surgical access include the transpalatal, Lefort I maxillotomy, medial maxillectomy, facial translocation, or infratemporal fossa approaches. We employed an intranasal endoscopic technique for resection of a JNA which was limited to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa.
0385-8146/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 8 5 - 8 1 4 6 ( 9 7 ) 1 0 0 0 6 - 2
40
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
2. Case report A 13 year old white male presented to the emergency room with a 2 year history of intermittent right-sided epistaxis and nasal congestion. Intranasal endoscopic examination revealed a smooth, polypoid mass filling the posterior nasal cavity and extending medially and inferiorly to the posterior third of the middle turbinate (Fig. 1). The remainder of the physical examination was normal. Bleeding was controlled using a hemostatic nasal sponge. Axial and coronal CT images obtained with intravenous contrast showed a mass filling the right posterior nasal cavity extending from the nasopharynx into the pterygopalatine fossa (Fig. 2). External carotid arteriography demonstrated an intensely vascular mass supplied by the distal internal maxillary artery (Fig. 3). The distal internal maxillary and ascending pharyngeal arteries were embolized with polyvinyl alcohol and microcoils. Contrast injection after embolization
Fig. 1. Smooth polypoid mass (T) filling the posterior nasal cavity and extending medially and inferiorly to the middle turbinate (M), extending inferiorly to the level of the inferior turbinate (I).
Fig. 2. Axial contrast enhanced CT scan shows a mass in the right posterior nasal cavity (T). The mass extends through the posterior choana into the nasopharynx and through the sphenopalatine foramen into the pterygopalatine fossa.
demonstrated marked reduction in the vascularity of the mass. The patient was taken to the operating room within 24 h of embolization. The packing was removed, and 0.05% oxymetazoline soaked pledgets were placed intranasally. Under endoscopic control, the septum, the base of the angiofibroma and the middle and inferior turbinates were
Fig. 3. Lateral view of an external carotid injection shows a large, enhancing mass supplied by the internal maxillary artery.
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
infiltrated with 1% xylocaine with epinephrine 1:100 000. The base of the JNA along the postero-lateral nasal wall and the roof of the nasal cavity was dissected using bipolar electrocautery. In order to improve visualization, the tumor was debulked and the margins were reexcised using blunt dissection and bipolar electrocautery. Tumor erosion of the face of the sphenoid sinus, which was noted on the preoperative CT scan, was confirmed intraoperatively. Next, the portion of the tumor extending into the pterygopalatine fossa (PPF) was addressed. The middle turbinate was lateralized and mucosa covering the posterior aspect of the maxillary sinus was elevated. Bone was removed from the posterior wall of the maxillary sinus and the sphenopalatine artery cauterized. After complete tumor removal, the nose was then packed with a nasal tampon. Total time in the operating room was 3 h and blood loss was approximately 100 cm3. The patient did well postoperatively and was discharged the following day. The packing was removed 3 days later. Microscopic pathology was consistent with JNA. Two months postoperatively, follow up endoscopic examination revealed an erythematous mass in the region of the sphenopalatine foremen. CT demonstrated minimal abnormal soft tissue along the posterior roof of the right nasal cavity which was felt to be residual tumor or scar (Fig. 4). To rule out recurrence, intraoperative biopsy of the mass was elected. Using endoscopic visualization, the periphery of the lesion was cauterized and the mass bluntly elevated. Further bone removal of the posterior wall of the maxillary sinus allowed wide exposure of the PPF. The pedicle of the dissected specimen was then cauterized and removed. A small amount of persistent bleeding in the PPF was controlled with Oxycel and a hemostatic sponge. The patient was discharged the following day and the packing was removed 3 days later in the office. Pathologic analysis revealed scar tissue with no evidence of residual angiofibroma. The patient remains disease free 25 months later (Fig. 5).
41
Fig. 4. Follow-up coronal CT scan shows only a small amount of soft tissue along the roof of the right nasal cavity. This could represent residual tumor or scar.
3. Discussion JNA is a rare benign tumor of unclear etiology found in adolescent and young adult males. Growth begins postero-laterally at the superior margin of the sphenopalatine foramen. This area forms the junction of the sphenoidal process of the palatine bone and the pterygoid process of the sphenoid bone. Growth can subsequently occur anteriorly into the nasal cavity, superiorly into the sphenoid or sella, or laterally through the
Fig. 5. 13 month follow-up with cavity free of disease.
42
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
Table 1 Surgical approaches for nasopharyngeal Tumor extension
Nasopharynx Nasal cavity Ethmoids Sphenoid sinus Pterygopalatine fossa Medial infratemporal fossa Medial cavernous sinus Lateral infratemporal fossa Medial cavernous sinus Lateral cavernous sinus Middle cranial fossa
Surgical approaches ESS
T-palate
Le Forte 1
M-Max
ITF
TX facial
Facial TX
x x x x
x x
x x x x x x x
x x x x x x x
x
x
x
x x x x x x x x x x x
x x x x x x x x x x x
x
x x x x x x x
Adapted from [12]. ESS, endoscopic; T-palate, transpalatal; M-Max, medial maxillectomy; IT, infratemporal fossa; TX facial, transfacial; Facial TX, facial translocation.
sphenopalatine foramen into the PPF. The lesion can also continue to expand further laterally via the pterygomaxillary fissure into the infratemporal fossa. Several routes of intracranial extension have been identified: (1) From the infratemporal fossa through the floor of the middle cranial fossa; (2) from the pterygomaxillary fissure along foramen rotundum into the cavernous sinus; (3) from the sphenoid sinus via the superior wall into the cavernous sinus and/or pituitary fossa [2]; and (4) from PPF through vidian canal. Different staging systems have been proposed for JNA, but are rarely useful prospectively because most institutions have not adopted any single staging system [3–8]. Surgical resection is the therapeutic modality of choice for most extracranial JNA. Refinement of surgical techniques, coupled with improved preoperative planning, utilizing CT scanning and angiography with embolization, have decreased the morbidity and mortality of resection. The role of radiation therapy has been reserved for patients refusing surgery, those with surgically inaccessible intracranial extensions of tumor and those with significant medical contraindications to surgical intervention. Goepfert et al. [9] reported five cases of angiofibroma successfully treated with chemotherapy. Chemotherapy is recommended
for treatment of recurrent lesions not amenable to surgery or radiation. Although spontaneous regression after puberty has been suggested, the evidence for this is scanty; to date only two documented cases exist in the English language literature [10,11]. The surgical approach is dictated by the topographic localization and extent of the tumor as well as the experience of the surgical team. Table 1 shows the options for surgical access according to tumor location [12]. Included is the intranasal endoscopic approach which will allow excision of tumors confined to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa. The advantages of the intranasal endoscopic technique are minimal soft tissue and bone trauma, improved cosmesis and patient comfort and shortened hospital stay. The avoidance of extensive soft tissue and bone disruption lessens the potential impact on craniofacial growth. Several studies have examined the effect of craniofacial surgery on the development of the facial bones. Although the detailed findings of experimental animal models are not necessarily applicable to humans, certain general principles have been established. Dissection of soft tissue from the facial bones may restrict facial growth and
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
facial osteotomies may lead to growth retardation [13–20]. Metal plating of the cranial vault or across suture lines has been shown to restrict local bone growth [13,16,21,22]. Normal facial bone development is dependent on normally functioning facial and masticatory muscles and normal trigeminal and facial nerve function [18,19,23]. Disadvantages of the endoscopic approach include limited access, tedious and piece-meal dissection and limited visibility due to bleeding and tumor bulk. The skill and judgement of the endoscopic surgeons are vitally important and the surgeon must be familiar with alternative approaches. Close follow-up after endoscopic excision is required. Batsakis [24] reported that symptomatic recurrences occur during the first 12 months after primary treatment and are unusual after 2 years. The endoscope is a valuable adjunct to serial radiologic examinations for the early detection of recurrent disease. The ready availability of rigid endoscopes in office practice should aid in the diagnosis of JNA at an earlier stage, allowing for endoscopic excision. Only the experienced endoscopist, cognizant of the advantages and limitations of the endoscopic approach, should attempt this form of intervention. Further experience and longterm follow up is required. The use of the rigid endoscope to supplement standard techniques is also being explored.
References [1] McCary WS, Gross CW, Reibel JF, Cantrell RW. Preliminary report: Endoscopic versus external surgery in the management of inverting papilloma. Laryngoscope 1994;104:415 – 9. [2] Neel HB, Whicker JH, Devine KD. Juvenile anglofibroma-a review of 120 cases. Am J Surg 1973;126:547– 60. [3] Sessions RB, Bryan R, Naclerio R, Alford B. Radiographic staging of juvenile angiofibroma. Head Neck Surg 1981;3:279 – 83. [4] Tandon DA, Bahadur S, Kacker SK, Goulatia RK. Nasopharyngeal angiofibroma: A nine year experience. J Laryngol Otol 1988;102:805–9.
43
[5] Antonelli AR, Cappeillo J, Dilorenzo D, Donajo CA, Nicolai P, Orlandini A. Diagnosis, staging, and treatment of juvenile nasopharyngeal angiofibroma. Laryngoscope 1987;97:1319 – 25. [6] Chandler JR, Goulding R, Moskowitz L, Quencher R. Nasopharyngeal angiofibroma: Staging and management. Ann Otol Rhinol Laryngol 1984;93:322 – 9. [7] Mishra SC, Shukla GK, Bhatia N, Pant MC. A rational classification of angiofibromas of the post nasal space. J Laryngol Otol 1989;103:912 – 6. [8] Andrews JC, Fisch U, Valavanis A, Aeppli U, Makek MS. The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach. Laryngoscope 1989;99:429 – 37. [9] Goepfert H, Cangir A, Lee YY. Chemotherapy for aggressive juvenile angiofibromas. Laryngoscope 1985;111:285 – 9. [10] Jacobsson M, Petruson B, Ruth M, Svendson P. Involution of juvenile nasopharyngeal angiofibroma with intracranial extension. Arch Otolaryngol Head Neck Surg 1989;115:238 – 9. [11] Weprin LS, Seimers PT. Spontaneous regression of juvenile nasopharyngeal angiofibroma. Arch Otlaryngol Head Neck Surg 1991;117:796 – 9. [12] Fagan JJ, Snyderman CH, Carrau RL, Janecka IP. Nasopharyngeal angiofibromas-selecting a surgical approach. Head Neck 1997;391 – 7. [13] Batsakis JG. Tumors of the head and neck: Clinical and pathological considerations. 2nd edn. Baltimore: Williams and Wilkins, 1979. [14] Laurenzo JF, Canady JW, Zimmerman MB, Smith JH. Craniofacial growth in rabbits: Effects of midfacial surgical trauma and rigid plate fixation. Arch Otolaryngol Head Neck Surg 1995;1221:556– 61. [15] Freihofer HPM. The timing of facial osteotomies in children and adolescents. Clin Plast Surg 1982;9:445 – 56. [16] Shapiro PA, Kokich VG, Hohl TH. The effects of early Le Fort I osteotomies on the craniofacial growth of juvenile Macaca nemestrina monkeys. Am J Orthod 1981;79:492 – 9. [17] Wong L, Dufesne CR, Richtsmeier JT, Manson PN. The effect of rigid fixation on growth of the neurocranium. Plast Reconstr Surg 1991;88:395 – 403. [18] Ousterhout DK, Vargervik K. Maxillary hypoplasia secondary to midfacial trauma in childhood. Plast Reconstr Surg 1987;80:491 – 7. [19] Del Campo AF, Elizondo MM, Magnelli LM, Valadez AS, Ontiveros DS. Craniofacial development in rats with early resection on the zygomatic arch. Plast Reconstr Surg 1995;95:486 – 95. [20] Jacobs B, Kronman JH. The zygomatic arch and its possible influence on craniofacial growth and development. Angle Orthod 1977;47:136 – 40. [21] Nandra R, Sugawara J, Topazian RG. Effect of maxillary osteotomy on subsequent craniofacial growth in adolescent monkeys. Am J Orthod 1983;83:391 – 407.
44
M.T. Mitska6ich et al. / Auris Nasus Larynx 25 (1998) 39–44
[22] Eppley BL, Platis JM, Sadove AM. Experimental effects of bone plating in infancy on the craniomaxillofacial skeletal growth. Cleft Palate-Craniofac J 1993;30:164–9. [23] Lin KY, Bartlett SP, Yaremchuk MJ, Grossman RF, Upupa JK, Whitaker LA. An experimental study on the
effect of rigid fixation on the developing craniofacial skeleton. Plast Reconstr Surg 1991;87:229 – 35. [24] Behrents RG, Johnston LE. The influence of the trigeminal nerve on facial growth and development. Am J Orthod 1984;85:199 – 206.
.