title: Surgery for juvenile nasopharyngeal angiofibroma with lateral extension to the infratemporal fossa.
abstract: OBJECTIVE
  The study aimed to assess the usefulness of skull base surgery for large juvenile nasopharyngeal angiofibroma (JNA) with lateral extension to the infratemporal fossa.
  
  
  METHODS
  Eleven cases were enrolled for this study, and the mean age was 17.7 years old (range: 8-32). Six out of 11 cases underwent surgery as an initial treatment, and the other five underwent secondary surgery after initial surgery or radiotherapy in other institutions. The range of extension of tumor, feeding arteries, surgical approach, and treatment outcome were estimated.
  
  
  RESULTS
  All tumors originated from the sphenopalatine foramen. Based on the imaging study, there was extension to the cavernous sinus observed in eight cases, as well as to the middle cranial fossa (8), orbit (4), and anterior cranial fossa (1). These tumors were diagnosed as Andrews' Stage IVa (3) and IVb (8). However, infiltration into the cavernous sinus was observed in one case only during surgery. Ten tumors were separated carefully from the cavernous sinus or dura and were accurately diagnosed as Stage IIIb. In all cases, the main arterial feeders of the JNAs were branches of the external carotid artery, which were embolized prior to surgery. However, 10 cases were also fed by branches of the internal carotid artery (branches of the ophthalmic artery), in which these arteries could not be embolized. Coronal skin incision (1) and a facial dismasking flap (9) were used, and in one case, wide lateral skin incision with temporary incision of the facial nerve was applied. The orbito-zygomatic approach and its modification was applied to all the cases. Fronto-lateral craniotomy was applied in four cases and lateral craniotomy in seven cases. Total resection was achieved in 10 cases and subtotal resection in one case. No mortality was noted in this series. Temporal trismus was observed in all cases which subsided gradually. Cheek numbness and facial palsy were observed in three and two cases, respectively.
  
  
  CONCLUSIONS
  Coupled with craniotomy, tumor removal was successfully carried out in 11 patients with JNAs, which showed large lateral extension. Our surgical strategy is a safe and effective approach for the removal of JNAs with infratemporal fossa extension.
authors.affiliation: Department of Otolaryngology, Tokyo Medical and Dental University, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Yamada
authors.affiliation: Department of Otolaryngology, Tokyo Medical and Dental University, Japan. Electronic address: atsunoda@mac.com.
authors.forename: Atsunobu
authors.initials: A
authors.lastname: Tsunoda
authors.affiliation: Department of Otolaryngology, Tokyo Medical and Dental University, Japan.
authors.forename: Takao
authors.initials: T
authors.lastname: Tokumaru
authors.affiliation: Department of Neurosurgery, Tokyo Medical and Dental University, Japan.
authors.forename: Masaru
authors.initials: M
authors.lastname: Aoyagi
authors.affiliation: Department of Neurosurgery, Tokyo Medical and Dental University, Japan.
authors.forename: Yoshihisa
authors.initials: Y
authors.lastname: Kawano
authors.affiliation: Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, Japan.
authors.forename: Tomoyuki
authors.initials: T
authors.lastname: Yano
authors.affiliation: Department of Head & Neck Surgery, Tokyo Medical and Dental University, Japan.
authors.forename: Seiji
authors.initials: S
authors.lastname: Kishimoto
mesh_terms: D000293:Adolescent; D000328:Adult; D018322:Angiofibroma / Q000098:blood supply / Q000473:pathology* / Q000601:surgery*; D002426:Cavernous Sinus / Q000473:pathology; D002648:Child; D003399:Craniotomy / Q000379:methods; D004621:Embolization, Therapeutic; D006801:Humans; D008297:Male; D009303:Nasopharyngeal Neoplasms / Q000098:blood supply / Q000473:pathology* / Q000601:surgery*; D016896:Treatment Outcome
keywords: Craniotomy; Infratemporal fossa; Juvenile nasopharyngeal angiofibroma; Orbito-zygomatic approach; Sphenopalatine foramen