title: In defence of transpalatal, transpalatal-circumaxillary (transpterygopalatine) and transpalatal-circumaxillary-sublabial approaches to lateral extensions of juvenile nasopharyngeal angiofibroma.
abstract: BACKGROUND
  Juvenile nasopharyngeal angiofibroma often presents with lateral extensions. In countries with limited resources, selection of a cost-effective and least morbid surgical approach for complete excision is challenging.
  
  
  METHODS
  Sixty-three patients with juvenile nasopharyngeal angiofibroma, with lateral extensions, underwent transpalatal, transpalatal-circumaxillary (transpterygopalatine) or transpalatal-circumaxillary-sublabial approaches for resection. Clinico-radiological characteristics, tumour volume and intra-operative bleeding were recorded.
  
  
  RESULTS
  The transpalatal approach was suitable for extensions involving medial part of pterygopalatine fossa; transpalatal-circumaxillary for extensions involving complete pterygopalatine fossa, with or without partial infratemporal fossa; and transpalatal-circumaxillary-sublabial for extensions involving complete infratemporal fossa, even cheek or temporal fossa up to zygomatic arch. Haemorrhage was greatest with the transpalatal-circumaxillary-sublabial approach, followed by transpalatal approach and transpalatal-circumaxillary approach (1212, 950 and 777 ml respectively). Tumour size (volume) was greatest with the transpalatal-circumaxillary approach, followed by transpalatal-circumaxillary-sublabial approach and transpalatal approach (40, 34 and 29 mm3). There was recurrence in three cases and residual disease in two cases. Long-term morbidity included small palatal perforation (n = 1), trismus (n = 1) and atrophic rhinitis (n = 2).
  
  
  CONCLUSIONS
  These modified techniques, performed with endoscopic assistance under hypotensive anaesthesia, without embolisation, offer a superior option over other open procedures with regard to morbidity and recurrences.
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: A
authors.initials: A
authors.lastname: Mishra
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: S C
authors.initials: SC
authors.lastname: Mishra
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: V
authors.initials: V
authors.lastname: Verma
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: H P
authors.initials: HP
authors.lastname: Singh
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: S
authors.initials: S
authors.lastname: Kumar
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: A M
authors.initials: AM
authors.lastname: Tripathi
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: B
authors.initials: B
authors.lastname: Patel
authors.affiliation: Department of Otorhinolaryngology,King George Medical University,Lucknow,India.
authors.forename: V
authors.initials: V
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D018322:Angiofibroma / Q000150:complications / Q000473:pathology / Q000601:surgery*; D016063:Blood Loss, Surgical; D002648:Child; D004844:Epistaxis / Q000209:etiology; D006261:Headache / Q000209:etiology; D006801:Humans; D008297:Male; D015508:Nasal Obstruction / Q000209:etiology; D009303:Nasopharyngeal Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery*; D013517:Otorhinolaryngologic Surgical Procedures / Q000379:methods*; D010159:Palate; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D056739:Pterygopalatine Fossa; D047368:Tumor Burden; D055815:Young Adult
keywords: Angiofibroma; Nasopharyngeal Neoplasms