Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis

Investigation of vascularization patterns in juvenile Angiofibroma and the impact of preoperative embolization on surgical excision

BACKGROUND

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, highly vascular tumor posing a significant challenge for endoscopic excision due to excessive intraoperative bleeding. Exploring feeding vessels and preoperative embolization could reduce intraoperative blood loss and improve surgical outcomes for JNA. This study investigates the vascularization patterns of JNA and the impact of preoperative embolization on surgical excision.

METHODS

This was a descriptive cross-sectional study of 30 histopathologically confirmed JNA patients who underwent preoperative embolization followed by endoscopic surgical excision from January 2019 to May 2023 at Ear Nose Throat Hospital of Ho Chi Minh City. The distribution of vascular supply of tumors, as well as the role of preoperative embolization, were analyzed.

RESULTS

Most tumors received exclusive blood supply from the internal maxillary artery (IMA) accounting for 50%, with 20% of cases being supplied by bilateral IMAs. A combined supply pattern involving the IMA and other external carotid artery branches was observed in 26.6%. Three complex cases (10%) received blood from the internal carotid artery (ICA). Embolization was performed at branches originating from the external carotid artery (ECA) but not from the ICA to avoid complications. All patients achieved complete endoscopic JNA excision. The average intraoperative blood loss was 608 mL (range: 100 mL - 3000 mL), and the average Boezaart score was 2.63. No major surgical complications occurred in the perioperative period. Significant differences in blood loss were observed among different UPMC tumor stages (p < 0.001) and tumor sizes (p = 0.008). Advanced-stage tumors were more likely to have an ICA blood supply (p = 0.038).

CONCLUSION

Understanding the vascularization patterns of juvenile angiofibroma and the role of preoperative embolization can facilitate endoscopic excision of these tumors.

Five challenging presentations of juvenile nasopharyngeal angiofibroma: our experience in the diagnosis and endoscopic surgical management

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor originating from the pterygopalatine fossa and is the most common lesion of the nasopharynx. Its hypervascularity and complex anatomical extensions make selecting the most effective surgical approach intricate. All patients in this series were males, and their age ranged between 8 and 23 years. Extensions to the carotids, cavernous sinus, and infratemporal fossa were noted. In addition, intraoperative details with particular emphasis on the endoscopic two-surgeon transseptal approach were discussed. Nasal obstruction was the most reported symptom, whereas epistaxis was evident in two cases. Complete or near-complete resection of the tumor was achieved in all cases. Over the follow-up period, one patient underwent successful revision endoscopic excision after tumor regrowth. JNA can be completely excised with endoscopic techniques. For large tumors, creating a wider window by using a two-surgeon trans-septal approach is practical and defers the need for external resection.

Combined Direct Tumoral Puncture Embolization with Onyx and Trans-arterial Embolization for JNA

Onyx is a safe and effective embolic agent to utilize in the treatment paradigm of JNA. We present a tandem approach that combines trans-arterial embolization (TAE) with direct puncture embolization (DPE) with Onyx to limit blood loss and facilitate safe resection. Laryngoscope, 134:3568-3571, 2024.

The effect of preoperative embolization on giant cell tumors of the bone localized in the iliosacral region of the pelvis

INTRODUCTION

Giant cell tumors of the bone (GCTB) are aggressive neoplasms, with rare occurrences in the posterior pelvis and sacral area. Surgical challenges in this region include the inability to apply a tourniquet and limited cementation post-curettage due to proximity to neurovascular structures, leading to potential complications. This case-control study explores the impact of preoperative embolization on GCTB located in the iliosacral region.

METHODS

Five surgeries (January-December 2021) for pelvic GCTB (3 sacrum, 2 posterior ilium) were performed on four patients. Diagnosis was confirmed through preoperative CT-guided biopsies. One surgery involved curettage with PMMA cement filling, while four surgeries had curettage without cavity filling. Preoperative embolization of the tumor feeding vessel occurred approximately 16 h before surgery in two cases. Denosumab treatment was not administered.

RESULTS

Tumor volume, assessed by preoperative MRI, was comparable between patients with and without preoperative embolization (p = .14). Surgeries without embolization had a mean intraoperative blood loss of 3250 ml, erythrocyte transfusion volume of 1125 ml, and a mean surgical time of 114.5 min for two surgeries. Surgeries with preoperative embolization showed a mean intraoperative blood loss of 1850 ml, no erythrocyte transfusion requirement, and a mean surgical time of 68 min.

CONCLUSION

Curettage of GCTB in the posterior pelvis and sacrum presents challenges, with significant intraoperative blood loss impacting surgical time and transfusion needs. Preoperative embolization may be beneficial in reducing blood loss during surgery in these cases.

Juvenile Nasopharyngeal Angiofibroma: A Series of 96 Surgical Cases

Introduction  Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascularized tumor that affects almost exclusively male adolescents. Surgery is the treatment of choice for JNA. Objectives  The present study is a 42-year retrospective review of a series of JNA cases treated surgically without previous embolization. Methods  The present is a retrospective, descriptive study based on medical records of 96 patients with JNA who underwent microscopic or endoscopic excision without previous embolization from 1978 to 2020 in a single institution. The patients were categorized according to the Andrews et al. stage, and data were collected on age, gender, tumor staging, surgical approach, affected side, and outcome. Results  All patients were male, with an average age of 17 years. The predominant tumor stage consisted of type II, with 52.1%. A total of 33.3% of the patients were submitted to the microscopic technique and 66.7%, to the endonasal technique. The rate of intraoperative blood transfusion was of 17.7%. Conclusion  The present study reinforces that resection of JNA in various stages is viable without previous artery embolization.

Total Endoscopic or Endoscope-Assisted Excision of Non-embolized Advanced Juvenile Nasopharyngeal Angiofibroma: A Clinical Case Series

Background Surgical excision is the primary treatment for juvenile nasopharyngeal angiofibroma (JNA), but this procedure is challenging due to its high vascularity and local aggressiveness. Moreover, preoperative embolization is a subject of debate. Objective The objective of this study is to assess the efficacy, safety, and feasibility of endoscope-assisted excision as a surgical intervention for non-embolized advanced JNA. Materials and methods This case series involved six male patients (mean age: 16 years) with JNA, classified as stages Ⅱc to Ⅲb according to the Radkowski classification. None underwent preoperative embolization. Results Two stage Ⅱc cases underwent total endoscopic endonasal excision. One patient with stage Ⅲa and another with stage Ⅲb underwent surgery via an endoscope-assisted sublabial approach. Two patients, one with stage Ⅱc JNA and another with Ⅲb, underwent a two-stage procedure. Postoperative CT scans showed no residual disease at the six-month mark. On average, each procedure required 1.5 units of blood transfusion. One patient experienced intraoperative bleeding, whereas the remaining patients were free of any major complications. The mean operation duration was 175 minutes per procedure. The mean length of stay at the hospital was 3.75 days per procedure. Conclusion Endoscope-assisted or purely endoscopic approaches can be safely and effectively employed for the complete excision of non-embolized advanced JNAs.

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

Case of giant juvenile angiofibroma resected by external incision with temporary double balloon occlusion of the internal carotid artery by intraoperative endovascular treatment

We report the first case of a juvenile nasal angiofibroma (JNA) fed by multiple arteries from the internal carotid artery (ICA), removed without complications by temporarily blocking the ICA with two balloons. An early adolescent with JNA underwent preoperative embolisation of feeding arteries arising from the external carotid artery (ECA) (University of Pittsburgh Medical Centre classification IV). Endoscopic resection was attempted once but discontinued due to massive bleeding (7000 mL). 17 months later, the JNA had grown to fill both nasal cavities. Repeated preoperative embolisation of the feeders from the ECA was performed, followed by surgery combined with endoscopic and external incision. Intraoperatively, two balloons were inserted into the right ICA, which were inflated at the proximal and distal sites of the feeder vessels to cut-off blood flow to the tumour. The tumour was almost completely resected with 6270 mL of blood loss and no postoperative neurological deterioration.

Endoscopic management of sinonasal tumours in the Nordic university hospitals: a survey

PURPOSE

The Nordic countries (27 M) all have comparable, publicly funded healthcare systems, and the management of sinonasal tumours is centralised to the 21 university hospitals. We sought to assess and compare the treatment practice of sinonasal tumours across the Nordic countries.

METHODS

A web-based questionnaire was sent to all university hospital departments of otorhinolaryngology-head and neck surgery in the Nordic countries.

RESULTS

Answers were obtained from all 21 Nordic university hospitals. The endoscopic approach was widely utilised by all, with most (62%) centres reporting 3-4 surgeons performing endoscopic sinonasal tumour surgery. Finland reported the lowest rates of centralisation among university hospitals despite having the highest number of 0.1-1 M catchment population hospitals. Most centres (88%) opted for the endoscopic approach in a patient case warranting medial maxillectomy. In a case of a Kadish C esthesioneuroblastoma, most (52%) of the centres preferred an endoscopic approach. Most centres (62%) reported favouring the endoscopic approach in a case describing a juvenile angiofibroma. Regarding a case describing a sinonasal undifferentiated carcinoma, consensus was tied (38% vs. 38%) between endoscopic resection followed by postoperative (chemo)radiotherapy (RT/CRT) and induction chemotherapy followed by RT/CRT or surgery followed by RT/CRT.

CONCLUSION

Endoscopic approach was widely utilised in the Nordic countries. The case-based replies showed differences in treatment practice, both internationally and nationally. The rate of centralisation among university hospitals remains relatively low, despite the rarity of these tumours.

Preoperative Embolization of Primary Juvenile Nasopharyngeal Angiofibroma: Is Embolization of Internal Carotid Artery Branches Necessary?

PURPOSE

To determine the effects of blood supply from internal carotid artery (ICA) on the surgical outcomes of primary juvenile nasopharyngeal angiofibroma (JNA) after transarterial embolization (TAE).

METHODS

A retrospective analysis was performed on primary JNA patients who underwent TAE and endoscopic resection in our hospital between December 2020 and June 2022. The angiography images of these patients were reviewed, and then they were divided into ICA + external carotid artery (ECA) feeding group and ECA feeding group according to whether the ICA branches were part of the feeding arteries. Tumors in ICA + ECA feeding group were fed by both ICA and ECA branches, while tumors in ECA feeding group were fed by ECA branches alone. All patients underwent tumor resection immediately after ECA feeding branches embolization. None of the patients underwent ICA feeding branches embolization. Data on demographics, tumor characteristics, blood loss, adverse events, residual and recurrence were collected, and case-control analysis was performed for the two groups. Differences in characteristics between the groups were tested using Fisher's exact and Wilcoxon tests.

RESULTS

Eighteen patients were included in this study: nine in ICA + ECA feeding group and nine in ECA feeding group. The median blood loss was 700 mL (IQR 550-1000 mL) in ICA + ECA feeding group versus 300 mL (IQR 200-1000 mL) in ECA feeding group, with no significant statistical difference (P = 0.306). Residual tumor was found in one patient (11.1%) in both groups. Recurrence was not observed in any patient. There were no adverse events from embolization and resection in either group.

CONCLUSION

The results of this small series suggest that the presence of blood supply from ICA branches in primary JNA has no significant effect on intraoperative blood loss, adverse event, residual and postoperative recurrence. Therefore, we do not recommend routine preoperative embolization of ICA branches.

LEVEL OF EVIDENCE

Level 4, Case-control.