Juvenile Nasopharyngeal Angiofibroma: Combined Approach for Excision, Transpalatal and Endoscopic; A New Perspective

Modified endoscopic endonasal approach with a minimally invasive transoral approach-an adjunct to infrapetrous approaches

OBJECTIVES/HYPOTHESIS

To evaluate the potential of a minimally invasive transoral-transpalatal approach (MITA) to the retrocarotid petrous apex, as an adjunct to endoscopic endonasal approaches (EEAs).

STUDY DESIGN

Cadaver study.

METHODS

Five cadaveric specimens were dissected raising an inverted U-shaped palatal mucoperiosteal flap, and drilling a rectangular palatotomy (between the greater palatine foramens, and just anterior to the palatine aponeurosis). This allowed a transpterygoid EEA with cross-court access (contralateral line of sight), followed by an extradural clivectomy that exposed the petroclival junction bilaterally. Surgical targets were marked on the posterior and medial surface of the petrous internal carotid artery (ICA), at its anterior genu, midhorizontal portion, and posterior genu. For each target and approach, the surgical freedom and angles of approach (in the horizontal and vertical planes) were calculated and statistically compared.

RESULTS

Compared to EEA, the MITA resulted in greater surgical freedom for all targets, with the highest values at the anterior genu (1,661.37 mm² vs. 312.76 mm² , P <.001), and maintaining superiority in this regard all the way to the posterior genu (847.84 mm³ vs. 138.91 mm³ , P < .005). MITA also offered greater angles of approach for all targets.

CONCLUSIONS

This study suggests that the MITA may be indicated to supplement the exposure provided by a transpterygoid EEA. This technique, associated with low potential morbidity, offers an alternative to internal carotid lateralization while managing extradural lesions that are adjacent to the petrous ICA.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:339-343, 2019.

Nasopharyngeal angiofibroma in an elderly female patient: A rare case report

'Juvenile' nasopharyngeal angiofibroma, which accounts for <1% of all head and neck neoplasms, occurs predominantly in males between 10 and 18 years of age. The small number of patients older than 30 years confirms that presentation after this age is exceptional. Only rare cases of nasopharyngeal angiofibroma in female patients have been documented to date, and some authors believe that sex chromosome studies are indicated in such cases. The pathogenesis of nasopharyngeal angiofibroma remains unknown, but it has been hypothesized that it is a testosterone-dependent tumor. We herein report a particularly rare case of a 68-year-old woman diagnosed with nasopharyngeal angiofibroma and describe the diagnostic and therapeutic workup. This case describes, to the best of our knowledge, the oldest patient reported in the literature.