title: Endoscopic graduated multiangle, multicorridor resection of juvenile nasopharyngeal angiofibroma: an individualized, tailored, multicorridor skull base approach.
abstract: OBJECT Juvenile nasopharyngeal angiofibromas (JNAs) are formidable tumors because of their hypervascularity and difficult location in the skull base. Traditional transfacial procedures do not always afford optimal visualization and illumination, resulting in significant morbidity and poor cosmesis. The advent of endoscopic procedures has allowed for resection of JNAs with greater surgical freedom and decreased incidence of facial deformity and scarring. METHODS This report describes a graduated multiangle, multicorridor, endoscopic approach to JNAs that is illustrated in 4 patients, each with a different tumor location and extent. Four different surgical corridors in varying combinations were used to resect JNAs, based on tumor size and location, including an ipsilateral endonasal approach (uninostril); a contralateral, transseptal approach (binostril); a sublabial, transmaxillary Caldwell-Luc approach; and an orbitozygomatic, extradural, transcavernous, infratemporal fossa approach (transcranial). One patient underwent resection via an ipsilateral endonasal uninostril approach (Corridor 1) only. One patient underwent a binostril approach that included an additional contralateral transseptal approach (Corridors 1 and 2). One patient underwent a binostril approach with an additional sublabial Caldwell-Luc approach for lateral extension in the infratemporal fossa (Corridors 1-3). One patient underwent a combined transcranial and endoscopic endonasal/sublabial Caldwell-Luc approach (Corridors 1-4) for an extensive JNA involving both the lateral infratemporal fossa and cavernous sinus. RESULTS A graduated multiangle, multicorridor approach was used in a stepwise fashion to allow for maximal surgical exposure and maneuverability for resection of JNAs. Gross-total resection was achieved in all 4 patients. One patient had a postoperative CSF leak that was successfully repaired endoscopically. One patient had a delayed local recurrence that was successfully resected endoscopically. There were no vascular complications. CONCLUSIONS An individualized, multiangle, multicorridor approach allows for safe and effective surgical customization of access for resection of JNAs depending on the size and exact location of the tumor. Combining the endoscopic endonasal approach with a transcranial approach via an orbitozygomatic, extradural, transcavernous approach may be considered in giant extensive JNAs that have intracranial extension and intimate involvement of the cavernous sinus.
authors.affiliation: Departments of 1 Neurological Surgery and.|Otolaryngology-Head Neck Surgery, and.|Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey.
authors.forename: James K
authors.initials: JK
authors.lastname: Liu
authors.affiliation: Otolaryngology-Head Neck Surgery, and.
authors.forename: Qasim
authors.initials: Q
authors.lastname: Husain
authors.affiliation: Otolaryngology-Head Neck Surgery, and.
authors.forename: Vivek
authors.initials: V
authors.lastname: Kanumuri
authors.affiliation: Otolaryngology-Head Neck Surgery, and.
authors.forename: Mohemmed N
authors.initials: MN
authors.lastname: Khan
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Zachary S
authors.initials: ZS
authors.lastname: Mendelson
authors.affiliation: Departments of 1 Neurological Surgery and.|Otolaryngology-Head Neck Surgery, and.|Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey.
authors.forename: Jean Anderson
authors.initials: JA
authors.lastname: Eloy
mesh_terms: D000293:Adolescent; D018322:Angiofibroma / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D002921:Cicatrix / Q000517:prevention & control*; D004621:Embolization, Therapeutic; D004724:Endoscopy / Q000379:methods*; D004954:Esthetics; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D009303:Nasopharyngeal Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D009361:Neoplasm Invasiveness; D011183:Postoperative Complications / Q000517:prevention & control*; D011300:Preoperative Care; D019292:Skull Base Neoplasms / Q000473:pathology / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D047368:Tumor Burden; D055815:Young Adult
keywords: ITF = infratemporal fossa; JNA = juvenile nasopharyngeal angiofibroma; PPF = pterygopalatine fossa; anterior skull base tumor; endoscopic anterior skull base tumor resection; infratemporal fossa; juvenile nasopharyngeal angiofibroma; oncology; sinonasal tumor; vascular sinonasal tumor