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Case Report
Juvenile Nasopharyngeal Angiofibroma: diagnosis and surgical treatment in I and II stage with dento-alveolar involvement L. Limongelli, R. Parrulli, A.P. Cazzolla, D. Di Venere, G. Favia Complex Operating Unit of Odontostomatology and Surgery, University of Bari, Italy Introduction. Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign, slowly growing, highly vascular and locally aggressive vasoformative neoplasm that presents most commonly in adolescent males with a median age of 14 years. The tumour generally originates from the superior margin of the sphenopalatine foramen. Lateral growth can put the tumor in the pterygomaxillary fossa pro-
Annali di Stomatologia 2013; Suppl. 2: 1-48
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Suppl.completo reimpag._4b_. 04/10/13 15:55 Pagina 26
ducing classic building of the cheek. We report the perioperative management and the different surgical approach of 6 JNA referred to I stage A and B and II stage A and B, according to Radkowski staging (’96). Cases presentation. 6 patients with JNA present epistaxis, nasal obstruction, facial numbness, check swelling, sinusitis and dento-alveolar involvement like wisdom teeth inclusions, confused with odontogenic cysts and tumours and so associated to intra-operative high risk of haemorrhage. They were evaluated by CT and carotid angiography to demonstrate tumour vascular composition and confirm diagnosis. Preoperative biopsy is not recommended due to a risk of profound hemorrhage. Carotid angiography also allows tumour embolization (24 hours before surgery), which reduces intraoperative bleeding. I stage JNA were removed via trans-palatal approach; II stage lesions were treated by trans-antral approach via Caldwell-Luc incision. Intra- and extra-lesional Diode Laser Photocoagulation (DLP) preceded surgical excision of irregular lump to obtain tumour decreasing. Results and conclusions. Trans-palatal and trans-antral approach were suitable for JNA complete removal and healing. DLP is useful to immediately reduce lesion size and simplifies surgical resection in the same session. At the median follow-up time of 26 months all patients remained free of diseases. JNA management has changed during the last decades, thanks to technological advances both in radiology (carotid angiography) and surgery (Diode Laser), but it still continues to be a challenge for the multidisciplinary surgical team. References • • •
26
Zixiang Yi, Zheming Fang, Gongbiao Lin, Chang Lin, Wenhui Xiao, Zhichun Li, Jinmei Cheng, Aidong Zhou. Nasopharyngeal angiofibroma: A concise classification system and appropriate treatment options. Am J Otolaryngol 2013 Mar-Apr; 34(2):133-41. Renkonen S, Hagström J, Vuola J, Niemelä M, Porras M, Kivivuori SM, Leivo I, Mäkitie AA. The changing surgical management of juvenile nasopharyngeal angiofibroma. Eur Arch Otorhinolaryngol 2011 Apr; 268(4):599-607. Hodges JM, McDevitt AS, El-Sayed Ali AI, Sebelik ME. Juvenile nasopharyngeal angiofibroma: current treatment modalities and future considerations. Indian J Otolaryngol Head Neck Surg July-September 2010; 236-247.
Annali di Stomatologia 2013; Suppl. 2: 1-48
Case Report
Juvenile Nasopharyngeal Angiofibroma: diagnosis and surgical treatment in I and II stage with dento-alveolar involvement L. Limongelli, R. Parrulli, A.P. Cazzolla, D. Di Venere, G. Favia Complex Operating Unit of Odontostomatology and Surgery, University of Bari, Italy Introduction. Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign, slowly growing, highly vascular and locally aggressive vasoformative neoplasm that presents most commonly in adolescent males with a median age of 14 years. The tumour generally originates from the superior margin of the sphenopalatine foramen. Lateral growth can put the tumor in the pterygomaxillary fossa pro-
Annali di Stomatologia 2013; Suppl. 2: 1-48
25
Suppl.completo reimpag._4b_. 04/10/13 15:55 Pagina 26
ducing classic building of the cheek. We report the perioperative management and the different surgical approach of 6 JNA referred to I stage A and B and II stage A and B, according to Radkowski staging (’96). Cases presentation. 6 patients with JNA present epistaxis, nasal obstruction, facial numbness, check swelling, sinusitis and dento-alveolar involvement like wisdom teeth inclusions, confused with odontogenic cysts and tumours and so associated to intra-operative high risk of haemorrhage. They were evaluated by CT and carotid angiography to demonstrate tumour vascular composition and confirm diagnosis. Preoperative biopsy is not recommended due to a risk of profound hemorrhage. Carotid angiography also allows tumour embolization (24 hours before surgery), which reduces intraoperative bleeding. I stage JNA were removed via trans-palatal approach; II stage lesions were treated by trans-antral approach via Caldwell-Luc incision. Intra- and extra-lesional Diode Laser Photocoagulation (DLP) preceded surgical excision of irregular lump to obtain tumour decreasing. Results and conclusions. Trans-palatal and trans-antral approach were suitable for JNA complete removal and healing. DLP is useful to immediately reduce lesion size and simplifies surgical resection in the same session. At the median follow-up time of 26 months all patients remained free of diseases. JNA management has changed during the last decades, thanks to technological advances both in radiology (carotid angiography) and surgery (Diode Laser), but it still continues to be a challenge for the multidisciplinary surgical team. References • • •
26
Zixiang Yi, Zheming Fang, Gongbiao Lin, Chang Lin, Wenhui Xiao, Zhichun Li, Jinmei Cheng, Aidong Zhou. Nasopharyngeal angiofibroma: A concise classification system and appropriate treatment options. Am J Otolaryngol 2013 Mar-Apr; 34(2):133-41. Renkonen S, Hagström J, Vuola J, Niemelä M, Porras M, Kivivuori SM, Leivo I, Mäkitie AA. The changing surgical management of juvenile nasopharyngeal angiofibroma. Eur Arch Otorhinolaryngol 2011 Apr; 268(4):599-607. Hodges JM, McDevitt AS, El-Sayed Ali AI, Sebelik ME. Juvenile nasopharyngeal angiofibroma: current treatment modalities and future considerations. Indian J Otolaryngol Head Neck Surg July-September 2010; 236-247.
Annali di Stomatologia 2013; Suppl. 2: 1-48
