Abstract
Juvenile nasopharyngeal angiofibroma (JNA) are fibrovascular tumors of the nasopharynx. These tumors are very vascular and non-encapsulated and predominantly affect young males aged 14–25 years. Clinically, JNA presents with unilateral nasal obstruction and recurrent epistaxis. Advanced instances may result in proptosis, cranial neuropathy, facial edema, and potentially fatal bleeding. The tumors exhibit local invasiveness which can extend intracranially. In this study, we reviewed two cases of extensive nasopharyngeal angiofibroma treated at our institute using the maxillary swing technique. The surgical approach was chosen based on tumor extent, blood supply, and the presence or absence of intracranial extension. Preoperatively, patients underwent tracheostomy and embolization. Both patients underwent successful surgical excision via the maxillary swing approach. We report the anticipated complications, their management, and the outcomes of these cases. Long-term follow-up revealed no recurrence, and both patients regained normal nasal function.
1
Introduction
Juvenile nasopharyngeal angiofibromas (JNAs) are fibrovascular tumors of the nasopharynx which represent 0.05 % of all head and neck neoplasms [ ]. These tumors are very vascular and non-encapsulated and predominantly affect young males aged 14–25 years [ ]. Traditionally, individuals with JNA show symptoms like unilateral nasal blockage and epistaxis [ ]. With increase in size there is extensive bleeding, proptosis, cranial neuropathy, and edema of the face. These tumors can expand beyond the maxillary sinus into the ethmoid and sphenoid sinuses, the infratemporal fossa and in more extreme situations, the orbit [ ]. They are locally invasive with chances of intracranial extension in 20 %–30 % of patients. Treatment options for JNAs include surgery, radiation therapy, chemotherapy and hormone therapy; of these, surgery is the most successful [ ]. After assessing the tumor’s size, blood supply, and existence or lack of cerebral expansion, the surgical strategy is determined [ ]. A variety of surgical techniques have been described for the excision of extensive and advanced nasopharyngeal angiofibroma, including the endoscopic endonasal approach, the maxillary swing approach, the craniofacial approaches, and the infratemporal fossa type C approach [ , ]. To report the expected difficulties, their care, and the results of these cases, the current study reviewed two cases of extensive juvenile nasopharyngeal angiofibroma that were operated on at our institute utilizing the maxillary swing technique.
2
Case note
2.1
Method
A retrospective case series of the two juvenile nasopharyngeal angiofibroma patients treated at our center was conducted. The Modified Fisch’s categorization scheme was employed [ ]. 2 cases of Stage IIIb and IVa were included in the study( Fig. 1 ). MRI evaluation was done for both patients, which showed enhanced lobulated soft tissue epicentered in the sphenopalatine foramen and extending to the infratemporal fossa ( Fig. 2 )
The nature, scope, and potential surgical alternatives were explained to patients and their families, along with the benefits and drawbacks of each. Prior to embolization and surgery, written informed consent was obtained from each patient. Pre-operative embolization of feeder vessels were done 48 hours before surgery. The maxillary swing approach was used in both cases. If there were complications, these were documented both during and after surgery.
2.2
Technique
General anesthesia was used on both patients. Elective tracheostomy was done in both patients preoperatively. Bilateral tarsorrhaphy stitch was taken. An incision was made on ipsilateral hemiface and across the midline palate using the Weber-Ferguson-Longmire technique. It was made across the ipsilateral hard and soft palates before curving and then ending at the maxillary tuberosity without extending it sublabially. The incision was deepened and the periosteum was reflected to expose the bone. The cheek flap and remaining periosteum were left attached to the maxilla’s anterior wall, with only a little portion of the periosteum lifted to reveal bone for necessary osteotomies. The inferior orbital rim, the zygomaticomaxillary suture line, and the midline of the maxillary alveolar processes were all plated with miniplates, and the necessary holes were bored for placement of screws ( Fig. 3 ). Osteotomies were performed at the frontal process of the maxilla, inferior orbital rim, zygomaticomaxillary suture, and midline palate in order to detach the maxilla from the pterygoid process. Then the entire maxilla, including the hard palate, was swung and reflected laterally while still connected to the cheek flap. The cranial base, infratemporal fossa, and entire nasopharynx was viewed clearly. A superior exposure encompassing the whole oropharynx, nasopharynx, and oral cavity was achieved by the lateral reflection of the maxilla. A significantly wider field of view could be achieved if we included the oral cavity in our surgical field. Complete tumor removal was done. ( Fig. 4 ). Any potential tumor remnants were examined in the sphenoid sinus, vidian canal, and pterygoid process. Maxilla repositioning was done at the osteotomy sites and fixation was done using miniplates and screws. The wound was primarily closed after the placing nasal packs. On the fourth post-operative day, the pack was taken out, and later in the follow-up period, palatal obturator was administered.
