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      Surgical Treatment of Non-embolized Patients with Nasoangiofibroma

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          Summary

          Juvenile nasopharyngeal angiofibroma (JNA) is an uncommon tumor of the sphenopalatine foramen. Surgery combined with preoperative embolization has been the treatment of choice for JNA patients without intracranial invasion. This study aims to assess the viability of surgically treating non-embolized patients with JNA (types I-III according to Fisch).

          Materials And Method

          This is a retrospective, descriptive study based on the medical records of 15 patients with histologically confirmed JNA (Fisch's types I- III), who underwent surgical treatment without pre-op embolization in our institution between 2000 and 2005.

          Results

          Seven of the fifteen patients were approached endoscopically, four through the transantral approach, three were treated with the combined transmaxillary and endoscopic approach, and one with the combined transmaxillary and transpalatal approach. Six patients required intraoperatory blood transfusion, averaging volumes of 1.3 unit/patient. There were no cases of death or significant morbidity. Eleven of the fifteen patients were followed for an average of twelve months and 27% of them relapsed. Four patients did not comply with the follow-up scheme.

          Conclusion

          Resection of JNF types I-III was safely completed in non-embolized patients. The observed levels of intraoperative bleeding, occurrence of complications, and rates of recurrence were close to those seen in embolized patients as found in the literature.

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          Most cited references27

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          The infratemporal fossa approach for nasopharyngeal tumors.

          U Fisch (1982)
          The technique and results of the infratemporal fossa surgical removal of carcinomas and juvenile angiofibromas of the nasopharynx are presented. Effective palliative removal of T4 and radical removal of T1 and T2 nasopharyngeal carcinomas was achieved. A classification of juvenile nasopharyngeal angiofibroma is presented. The infratemporal fossa approach allows radical removal of type III tumors and subtotal removal of type IV tumors. If residual tumor has to be left back in the cavernous sinus, irradiation is used to stop further growth of the tumor. If radiotherapy fails the neurosurgical removal of the intracranial portion of the tumor is indicated.
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            Arterial embolization in the management of posterior epistaxis.

            Treatment of severe epistaxis can encompass many modalities. Control rates with all treatments are good. Morbidity among treatment groups varies. Angiographic embolization is one such method that has a very low complication rate. Over the last 10 years, it has become the preferred treatment at our institution. Tertiary medical referral centers: OHSU, Portland VAMC. Retrospective review of 70 patients transferred or admitted with posterior epistaxis and treated with selective angiographic embolization from 1993 to 2002. Patients had bleeding for a median of 4.5 days prior to admission. 79% were unilateral. Etiology of bleeding was: idiopathic (61%), previous surgery (11%), anticoagulants (9%), trauma (7%), and other causes (12%). 30% required blood transfusions prior to admission to OHSU (average 4.4 units). No patient required a transfusion postoperatively following angiographic embolization or during their hospitalization. The internal maxillary artery (IMAX) was embolized in 94% (47% unilateral or bilateral IMAX only, 47% unilateral or bilateral IMAX in combination with other vessels, 6% other vessels besides the IMAX). Mean length of stay was 2.5 days. 86% had minor or no complications after the embolization and were discharged within 24 hours. 13% had a major rebleed that required surgical intervention within 6 weeks of the embolization. One patient had a serious neurological complication. Using the data available on 68 of 70 patients, the cost of hospitalization averaged dollar 18,000 with direct costs of embolization averaging dollar 11,000. Angiographic embolization is a clinically effective treatment for severe epistaxis. C.
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              Angiofibroma. Changes in staging and treatment.

              To identify specific preoperative tumor characteristics and potential surgical decisions that ultimately place a patient at a greater risk for tumor recurrence. The clinical presentation, management, and prognosis of 23 consecutive cases of juvenile nasopharyngeal angiofibroma were reviewed retrospectively from January 1, 1977, to June 30, 1993. A minimum follow-up of 12 months was necessary for study inclusion. A single, tertiary care pediatric facility. All available preoperative imaging studies were reevaluated to ensure consistency in reporting. Preoperative computed tomography was performed in 21 patients, but only 18 scans were available for review. Preoperative angiography with embolization was performed in 21 of 23 patients. Surgical excision was the primary mode of treatment in 22 of 23 patients, and complete surgical excision was possible in 21 of 23 patients. The rate of recurrence was examined with respect to time of presentations, initial tumor stage, intraoperative blood loss, and surgical approach. When compared with patients without a recurrent tumor, there was no difference in age at presentation, primary symptom, or duration of symptoms before diagnosis. Preoperative tumor stage was found to be the primary factor affecting tumor recurrence. A recurrence rate of 21.7% (five of 23 patients) was identified after an average 6-year follow-up. A trend toward use of the midfacial degloving approach for surgical exposure was identified and was not associated with an increased risk of recurrence. All patients were ultimately cured of their tumor without the need for open craniotomy despite a 32% incidence of stage IIIA and IIIB tumors. No deaths were reported during the study. Juvenile nasopharyngeal angiofibromas are benign tumors occurring almost exclusively in adolescent males. Recent advances in radiographic imaging techniques allow for more accurate preoperative staging, especially in regard to skull base involvement. Recognition of the extent of the tumor before surgical extirpation reduces the risk of recurrence.
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                Author and article information

                Journal
                Braz J Otorhinolaryngol
                Braz J Otorhinolaryngol
                Brazilian Journal of Otorhinolaryngology
                Elsevier
                1808-8694
                1808-8686
                18 October 2015
                Jul-Aug 2008
                18 October 2015
                : 74
                : 4
                : 583-587
                Affiliations
                [1 ]Specialist in ENT and head and neck surgery by the HC/ UNICAMP. Specialist in Forensic Medicine at SSP/BA, Adjunct Professor of head and neck surgery at Santa Casa de Misericórdia da Bahia - Hospital Santa Izabel. Specialist in swallowing disorders and head and neck surgery at the Núcleo de Otorrinolaringologia e Estudos da Voz/Hospital da Bahia /Hospital Português.
                [2 ]Specialist in ENT, otorhinolaryngologist, Adjunct Professor of rhinology at the ENT Department of the Santa Casa de Misericórdia da Bahia, Hospital Santa Izabel.
                [3 ]MSc in pathology at FIOCRUZ/ UFBA, PhD student at FIOCRUZ UFBA, Adjunct Professor of ENT at Santa Casa de Misericórdia da Bahia, Hospital Santa Izabel.
                [4 ]PhD in ENT at USP, Head of the ENT and Head and Neck Department at Santa Casa de Misericórdia da Bahia, Hospital Santa Izabel.
                [5 ]MD, Resident at the ENT and Head and Neck Surgery Department at Santa Casa de Misericórdia da Bahia, Hospital Santa Izabel.
                [6 ]MD, Resident at the ENT and Head and Neck Surgery Department at Santa Casa de Misericórdia da Bahia, Hospital Santa Izabel.
                [7 ]MD, Resident at the ENT and Head and Neck Surgery Department at Santa Casa de Misericórdia da Bahia, Hospital Santa Izabel. Santa Casa de Misericórdia da Bahia, Hospital Santa Izabel.
                Author notes
                [* ]Send correspondence to: Adriano Santana Fonseca - Unidade de Otorrinolaringologia e Cirurgia Cérvico-Facial do Hospital Santa Izabel. Praça Almeida Couto 500 Nazaré Salvador BA 40050-410.
                Article
                S1808-8694(15)30607-8
                10.1016/S1808-8694(15)30607-8
                9442087
                18852986
                3670e4cd-38bd-4c44-a3ef-f8836464ef69
                .

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 12 September 2007
                Categories
                Original Article

                treatment,embolization,juvenile nasopharyngeal angiofibroma,skull base

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