Combined approach for massive nasopharyngeal fibroma* By S. R. REGE, K. L. SHAH and S. A. KANTAWALA
(Bombay) excision of an extensive juvenile nasopharyngeal fibroma is a surgical challenge because of the limited field of work, inadequate visualization, and profuse haemorrhage during surgery. Besides these; deformity, scars, and adhesions as a result of prior surgery add to the problem. A benign tumour, known to be due to hormonal imbalance (Conley et al., 1968), juvenile nasopharyngeal fibroma occurs in males around puberty. It grows slowly and spreads along the natural ostia and fissures causing deformity and disability. This spread forms the extensions in massive tumours. These extensions are usually well-defined, free and have broad-based attachments to the main tumour mass in the nasopharynx. It is essential to know the possible extensions and their sites of spread before contemplating any surgery (Table I). COMPLETE
TABLE I PATHWAYS OF EXTENSIONS OF NASOPHARYNGEAL FIBROMA
Site of extension
Pathway
(a) Sphenoid, ethmoids, nose, oropharynx (b) Pterygopalatine fossa (c) (d) (e) (/)
Infra-orbital fissure Infra-temporal fossa Orbit Intracranial
Direct spread. Through sphenopalatine foramen. Through sinus of Morgagni. Through pterygopalatine fossa. Through pterygopalatine fossa. Through infra-orbital fissure. Through sphenoid sinus.
It has long been known that a combination of various approaches for excision of the tumour is essential when it has spread beyond the confines of the nasopharynx. Having witnessed advantages and disadvantages of various surgical approaches to the extensive tumour, we recommend a combination of the transpalatal and transmaxillary approaches. To excise the nasopharyngeal part and its intracranial extension, the transpalatal approach is essential. To extirpate the lateral extensions of the tumour, a transmaxillary approach in combination with the transpalatal approach provides the * Paper read at the 25th Annual Conference of Association of Otolaryngologists of India, held in Bombay, India. 1219
S. R. Rege, K. L. Shah and S. A. Kantawala maximum working space and adequate visualization. By excising the entire middle one-third of the maxilla and uniting the nasal cavity with the cheek (Fig. i) through the maxillary sinus and the pterygopalatine fossa, a large part of the retromaxillary tumour is exposed. The middle one-third of the maxilla consists of its lateral, medial and posterior walls, the roof being the superior part and the floor with its alveolar process being the inferior part. The inferior turbinate bone is removed with the maxillary sinus walls, since it is attached there.
FIG. I
X-ray picture after removal of middle 1/3 of maxilla.
Pre-operative preparation and assessment
The majority of these patients suffer from anaemia due to repeated epistaxis. Complete haemogram and blood grouping and crossmatching are essential. The anaemia, which is usually normochromic and normocytic in patients with this benign tumour, is corrected. One to i | litres of blood is kept ready for transfusion when the patient is taken up for surgical extirpation of the tumour. Radiography of the sinuses, nasopharynx and base of the skull helps to determine the various sites of spread by way of a soft-tissue shadow 1220
Combined approach for massive nasopharyngeal fibroma in the nasopharynx, widening of maxillo-mandibular space in Water's view (Fig. 2), or erosion of the basisphenoid in the basal skull view (Wilson and Harrafee, 1969). Carotid angiography helps to determine the vascular pattern of the tumour (Samy and Girgis, 1967) (Figs. 3 and 4).
FIG. 2 Water's view showing widening of maxillo-mandibular space on left side.
Anaesthesia
A closed-circuit technique, using N2O, 0 2 and halothane with tubarine, helps to reduce the bleeding and permits the use of cautery. A cuffed endotracheal tube and adequate pharyngeal packing are essential to prevent aspiration during surgery. Operative technique
Infiltration with adrenaline in normal saline (1 : 30,000) in the area of incision and dissection helps to reduce bleeding considerably. The maxilla is exposed through a Webber-Ferguson lip splitting incision on the side of lateral spread of the tumour. The middle one-third of the maxilla, as described earlier, is removed along with the inferior turbinate to expose the lateral extensions of the tumour. The main tumour mass in the nasopharynx has already been exposed earlier through a Wilson's transpalatine approach. The basisphenoid, pterygoid plates and occasionally the anterior surface of the upper cervical vertebrae are the sites where the periosteum provides attachments to the tumour. This is cut around the sites of attachment and the tumour is avulsed with the help of long, sharp dissectors/elevators and a couple of Luc's forceps. 1221
FIG.
3
FIG. 4 FIGS. 3 AND 4
Carotid angiogram showing 'tumour flush'.
Combined approach for massive nasopharyngeal fibroma It is essential to pack the raw area and the cavity so created to reduce and/or arrest the haemorrhage. Extensions which are deep to the pterygoid and temporalis muscles are now separated out by dissection, from the cheek side towards the main attachment, and removed. The third part of the maxillary artery is ligated in the pterygopalatine fossa during this process. It is ascertained that no part of the tumour is left behind by examining the surface of the extirpated tumour, which is always smooth if intact. Another criterion for total removal is almost complete stoppage of haemorrhage from the raw areas. The nasopharynx, nasal cavity and maxillary sinus are packed with gauze packs impregnated with sterilized petroleum jelly or furacin ointment. The incisions on the palate and the face are sutured in layers. Post-operatively, the nasopharyngeal pack is removed after 72 hours, under general anaesthesia, while the other packs are removed after four days. The facial sutures are removed on the sixth/seventh post-operative day. Complete healing occurs in about two weeks. Advantages 1. Direct access to the tumour. 2. Better visual control. 3. Ligation of the third part of the maxillary artery in the operative field. 4. No disfigurement in spite of extensive surgery. Complications (1) Gaping of the palatal wound occurred in two of the seven cases; it required resuturing under anaesthesia. (2) Post-operative rhinolalia occurred in all of these cases and lasted for about six to ten weeks post-operatively after which it disappeared. (3) Two of these cases required tracheostomy to prevent lung complications due to aspiration of exudate and secretions. There was no death, nor was there a recurrence in any one of them who had undergone a combined approach. Table II shows the number of cases operated by various approaches by the authors, totalling one hundred. Of these, seven had undergone surgery by the combined approach; three of them who were operated for recurrences are presented here. TABLE II VARIOUS APPROACHES USED
Number of cases 1. 2. 3. 4.
Transpalatal Lateral rhinotomy Trans-zygomatic Combined approach suggested here 1223
77 15 1 7
S. R. Rege, K. L. Shah and S. A. Kantawala TABLE III SURGERY SCHEDULE
Number of cases 1. 2. 3. 4.
Single operation One revision surgery Two revision surgery Three revision surgery
Table III shows the rate of recurrence; in all, eleven patients came in for recurrence. Recurrence, if any, usually presents itself within three to six months of surgery. Case records
Case 1 C.H., a male aged 16 years, was admitted in 1967 with a recurrence of juvenile nasopharyngeal fibroma. A year earlier, transpalatal excision had been done. There was a cheek swelling. Vision in the right eye was 6/60. There was no mass in the nose. Radiography confirmed a lateral spread, as the maxillomandibular space was widened in Water's view. Surgical excision was done by the combined approach. At the last follow-up in December 1972, there was no recurrence (Fig. 5).
V FIG. 5 Post-operative photograph of Case 1. 1224
Combined approach for massive nasopharyngeal fibroma Case 2
K.N., a male aged 15 years, operated thrice earlier, was admitted with occasional epistaxis, diminished vision in the right eye, ptosis and marked swelling of the right cheek. Clinically and radiographically his was a case of recurrence of nasopharyngeal fibroma. Total excision was performed through the combined approach in June 1969. A tracheostomy was performed postoperatively to prevent aspiration. At the last follow-up, three years after surgery, he had no recurrence (Figs. 6 and 7).
FIG. 6 Pre-operative photograph showing swelling of cheek (Case 2).
Case 3
L.R., a 14-year-old boy, was admitted in 1969 with a recurrence 4J months after the transpalatal excision of a nasopharyngeal fibroma. There was a lateral spread into the cheek. Excision was done through a combined approach in September 1969. There was no recurrence at the last follow-up in December 1972 (Fig. 8). Discussion It is essential to use a combined surgical approach for complete, sure extirpation of an extensive nasopharyngeal fibroma. In our opinion, a combination of transmaxillaiy and transpalatal routes provides the best 1225
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7 Post-operative photograph showing the scar (Case 2).
FIG.
8 Post-operative photograph showing the scar (Case 3). FIG.
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Combined approach for massive nasopharyngeal fibroma approach for surgery; the advantages have been presented earlier. There is little to prove to the contrary except for a scar on the face. ABSTRACT A combined approach by the transpalatal and transmaxillary routes has proved to be a better technique for total surgical extirpation of extensive nasopharyngeal fibroma, and it has been used already in seven cases without recurrence over a period of three years. The transmaxillary route includes removal of the middle one-third of the maxilla, i.e. the lateral, medial and posterior walls of the maxilla with the inferior turbinate bone. Acknowledgement Our thanks are due to the Dean, K.E.M. Hospital, Dean, L.T.M. General Hospital, Sion and Assistant Medical Officer, Seth A.J.B. Municipal E.N.T. Hospital, Bombay 400 001, India, for allowing the use of hospital material. REFERENCES CONLEY, J., HEALEY, W., BLANRUND, S. M.( and PERZIN,
K. (1968)
Surgery,
Gynecology and Obstetrics, 125, 825. SAMY, L. L., and GIRGIS, I. H. (1967) 'Blood Supply of Nasopharyngeal Fibroma'. Journal of Laryngology and Otology, 81, 1405. WILSON, G., and HARRAFEE, W. H. (1969) Radiology, 92, 279.
E.N.T. Department K.E.M. Hospital Bombay 400012 India Dr. S. A. Kantawala 9/212 Walkeshwar Road Bombay 400 006, India
I.227
(Bombay) excision of an extensive juvenile nasopharyngeal fibroma is a surgical challenge because of the limited field of work, inadequate visualization, and profuse haemorrhage during surgery. Besides these; deformity, scars, and adhesions as a result of prior surgery add to the problem. A benign tumour, known to be due to hormonal imbalance (Conley et al., 1968), juvenile nasopharyngeal fibroma occurs in males around puberty. It grows slowly and spreads along the natural ostia and fissures causing deformity and disability. This spread forms the extensions in massive tumours. These extensions are usually well-defined, free and have broad-based attachments to the main tumour mass in the nasopharynx. It is essential to know the possible extensions and their sites of spread before contemplating any surgery (Table I). COMPLETE
TABLE I PATHWAYS OF EXTENSIONS OF NASOPHARYNGEAL FIBROMA
Site of extension
Pathway
(a) Sphenoid, ethmoids, nose, oropharynx (b) Pterygopalatine fossa (c) (d) (e) (/)
Infra-orbital fissure Infra-temporal fossa Orbit Intracranial
Direct spread. Through sphenopalatine foramen. Through sinus of Morgagni. Through pterygopalatine fossa. Through pterygopalatine fossa. Through infra-orbital fissure. Through sphenoid sinus.
It has long been known that a combination of various approaches for excision of the tumour is essential when it has spread beyond the confines of the nasopharynx. Having witnessed advantages and disadvantages of various surgical approaches to the extensive tumour, we recommend a combination of the transpalatal and transmaxillary approaches. To excise the nasopharyngeal part and its intracranial extension, the transpalatal approach is essential. To extirpate the lateral extensions of the tumour, a transmaxillary approach in combination with the transpalatal approach provides the * Paper read at the 25th Annual Conference of Association of Otolaryngologists of India, held in Bombay, India. 1219
S. R. Rege, K. L. Shah and S. A. Kantawala maximum working space and adequate visualization. By excising the entire middle one-third of the maxilla and uniting the nasal cavity with the cheek (Fig. i) through the maxillary sinus and the pterygopalatine fossa, a large part of the retromaxillary tumour is exposed. The middle one-third of the maxilla consists of its lateral, medial and posterior walls, the roof being the superior part and the floor with its alveolar process being the inferior part. The inferior turbinate bone is removed with the maxillary sinus walls, since it is attached there.
FIG. I
X-ray picture after removal of middle 1/3 of maxilla.
Pre-operative preparation and assessment
The majority of these patients suffer from anaemia due to repeated epistaxis. Complete haemogram and blood grouping and crossmatching are essential. The anaemia, which is usually normochromic and normocytic in patients with this benign tumour, is corrected. One to i | litres of blood is kept ready for transfusion when the patient is taken up for surgical extirpation of the tumour. Radiography of the sinuses, nasopharynx and base of the skull helps to determine the various sites of spread by way of a soft-tissue shadow 1220
Combined approach for massive nasopharyngeal fibroma in the nasopharynx, widening of maxillo-mandibular space in Water's view (Fig. 2), or erosion of the basisphenoid in the basal skull view (Wilson and Harrafee, 1969). Carotid angiography helps to determine the vascular pattern of the tumour (Samy and Girgis, 1967) (Figs. 3 and 4).
FIG. 2 Water's view showing widening of maxillo-mandibular space on left side.
Anaesthesia
A closed-circuit technique, using N2O, 0 2 and halothane with tubarine, helps to reduce the bleeding and permits the use of cautery. A cuffed endotracheal tube and adequate pharyngeal packing are essential to prevent aspiration during surgery. Operative technique
Infiltration with adrenaline in normal saline (1 : 30,000) in the area of incision and dissection helps to reduce bleeding considerably. The maxilla is exposed through a Webber-Ferguson lip splitting incision on the side of lateral spread of the tumour. The middle one-third of the maxilla, as described earlier, is removed along with the inferior turbinate to expose the lateral extensions of the tumour. The main tumour mass in the nasopharynx has already been exposed earlier through a Wilson's transpalatine approach. The basisphenoid, pterygoid plates and occasionally the anterior surface of the upper cervical vertebrae are the sites where the periosteum provides attachments to the tumour. This is cut around the sites of attachment and the tumour is avulsed with the help of long, sharp dissectors/elevators and a couple of Luc's forceps. 1221
FIG.
3
FIG. 4 FIGS. 3 AND 4
Carotid angiogram showing 'tumour flush'.
Combined approach for massive nasopharyngeal fibroma It is essential to pack the raw area and the cavity so created to reduce and/or arrest the haemorrhage. Extensions which are deep to the pterygoid and temporalis muscles are now separated out by dissection, from the cheek side towards the main attachment, and removed. The third part of the maxillary artery is ligated in the pterygopalatine fossa during this process. It is ascertained that no part of the tumour is left behind by examining the surface of the extirpated tumour, which is always smooth if intact. Another criterion for total removal is almost complete stoppage of haemorrhage from the raw areas. The nasopharynx, nasal cavity and maxillary sinus are packed with gauze packs impregnated with sterilized petroleum jelly or furacin ointment. The incisions on the palate and the face are sutured in layers. Post-operatively, the nasopharyngeal pack is removed after 72 hours, under general anaesthesia, while the other packs are removed after four days. The facial sutures are removed on the sixth/seventh post-operative day. Complete healing occurs in about two weeks. Advantages 1. Direct access to the tumour. 2. Better visual control. 3. Ligation of the third part of the maxillary artery in the operative field. 4. No disfigurement in spite of extensive surgery. Complications (1) Gaping of the palatal wound occurred in two of the seven cases; it required resuturing under anaesthesia. (2) Post-operative rhinolalia occurred in all of these cases and lasted for about six to ten weeks post-operatively after which it disappeared. (3) Two of these cases required tracheostomy to prevent lung complications due to aspiration of exudate and secretions. There was no death, nor was there a recurrence in any one of them who had undergone a combined approach. Table II shows the number of cases operated by various approaches by the authors, totalling one hundred. Of these, seven had undergone surgery by the combined approach; three of them who were operated for recurrences are presented here. TABLE II VARIOUS APPROACHES USED
Number of cases 1. 2. 3. 4.
Transpalatal Lateral rhinotomy Trans-zygomatic Combined approach suggested here 1223
77 15 1 7
S. R. Rege, K. L. Shah and S. A. Kantawala TABLE III SURGERY SCHEDULE
Number of cases 1. 2. 3. 4.
Single operation One revision surgery Two revision surgery Three revision surgery
Table III shows the rate of recurrence; in all, eleven patients came in for recurrence. Recurrence, if any, usually presents itself within three to six months of surgery. Case records
Case 1 C.H., a male aged 16 years, was admitted in 1967 with a recurrence of juvenile nasopharyngeal fibroma. A year earlier, transpalatal excision had been done. There was a cheek swelling. Vision in the right eye was 6/60. There was no mass in the nose. Radiography confirmed a lateral spread, as the maxillomandibular space was widened in Water's view. Surgical excision was done by the combined approach. At the last follow-up in December 1972, there was no recurrence (Fig. 5).
V FIG. 5 Post-operative photograph of Case 1. 1224
Combined approach for massive nasopharyngeal fibroma Case 2
K.N., a male aged 15 years, operated thrice earlier, was admitted with occasional epistaxis, diminished vision in the right eye, ptosis and marked swelling of the right cheek. Clinically and radiographically his was a case of recurrence of nasopharyngeal fibroma. Total excision was performed through the combined approach in June 1969. A tracheostomy was performed postoperatively to prevent aspiration. At the last follow-up, three years after surgery, he had no recurrence (Figs. 6 and 7).
FIG. 6 Pre-operative photograph showing swelling of cheek (Case 2).
Case 3
L.R., a 14-year-old boy, was admitted in 1969 with a recurrence 4J months after the transpalatal excision of a nasopharyngeal fibroma. There was a lateral spread into the cheek. Excision was done through a combined approach in September 1969. There was no recurrence at the last follow-up in December 1972 (Fig. 8). Discussion It is essential to use a combined surgical approach for complete, sure extirpation of an extensive nasopharyngeal fibroma. In our opinion, a combination of transmaxillaiy and transpalatal routes provides the best 1225
8s
to
7 Post-operative photograph showing the scar (Case 2).
FIG.
8 Post-operative photograph showing the scar (Case 3). FIG.
63*
63.
63
on
63
on
r
en
Combined approach for massive nasopharyngeal fibroma approach for surgery; the advantages have been presented earlier. There is little to prove to the contrary except for a scar on the face. ABSTRACT A combined approach by the transpalatal and transmaxillary routes has proved to be a better technique for total surgical extirpation of extensive nasopharyngeal fibroma, and it has been used already in seven cases without recurrence over a period of three years. The transmaxillary route includes removal of the middle one-third of the maxilla, i.e. the lateral, medial and posterior walls of the maxilla with the inferior turbinate bone. Acknowledgement Our thanks are due to the Dean, K.E.M. Hospital, Dean, L.T.M. General Hospital, Sion and Assistant Medical Officer, Seth A.J.B. Municipal E.N.T. Hospital, Bombay 400 001, India, for allowing the use of hospital material. REFERENCES CONLEY, J., HEALEY, W., BLANRUND, S. M.( and PERZIN,
K. (1968)
Surgery,
Gynecology and Obstetrics, 125, 825. SAMY, L. L., and GIRGIS, I. H. (1967) 'Blood Supply of Nasopharyngeal Fibroma'. Journal of Laryngology and Otology, 81, 1405. WILSON, G., and HARRAFEE, W. H. (1969) Radiology, 92, 279.
E.N.T. Department K.E.M. Hospital Bombay 400012 India Dr. S. A. Kantawala 9/212 Walkeshwar Road Bombay 400 006, India
I.227
![[Hormone dependence of juvenile nasopharyngeal fibroma].](/assets/img/hold.png)
