title: Reducing intraoperative bleeding of juvenile nasopharyngeal angiofibroma.
abstract: OBJECTIVE
  To report the case of a young patient with juvenile nasopharyngeal angiofibroma (JNA) (Fisch grade IVb) operated on in a semisitting position.
  
  
  METHODS
  A 17-year-old boy complained of nasal obstruction and pain in the left periorbital area in April 2007. Magnetic resonance imaging (MRI) showed grade IVb JNA with invasion of the anterior cranial fossa, the cavernous sinuses, and the chiasm. Resections of the tumor through bifrontal craniotomy in June 2007 and through lateral rhinotomy in January 2008, both performed in the supine position, were complicated by excessive bleeding.
  
  
  RESULTS
  In February 2008, the lesion was removed through a transfacial approach in a semisitting position after transnasal and percutaneous embolization. The vascular support to the tumor was reduced by using high-power bipolar forceps, monopolar diathermy, and intratumoral injection of fibrin glue. The main part of the lesion was successfully removed.
  
  
  CONCLUSIONS
  The combination of preoperative embolization (transnasal, percutaneous, endovascular), semisitting positioning of the patient, intraoperative injection of fibrin glue, and high-power bipolar forceps and monopolar diathermy is helpful in reducing surgical bleeding and enabling safe resection of JNA.
authors.affiliation: Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland. rossana.romani@hus.fi
authors.forename: Rossana
authors.initials: R
authors.lastname: Romani
authors.forename: Hanna
authors.initials: H
authors.lastname: Tuominen
authors.forename: Juha
authors.initials: J
authors.lastname: Hernesniemi
mesh_terms: D000293:Adolescent; D018322:Angiofibroma / Q000097:blood / Q000473:pathology / Q000601:surgery*; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods*; D006470:Hemorrhage / Q000503:physiopathology / Q000517:prevention & control / Q000628:therapy*; D006801:Humans; D007431:Intraoperative Complications / Q000503:physiopathology / Q000517:prevention & control / Q000628:therapy*; D008297:Male; D009303:Nasopharyngeal Neoplasms / Q000098:blood supply / Q000473:pathology / Q000601:surgery*