Full text of DOI:10.1007/BF02910980

INTRODUCTION
JNA is a benign neoplasm of the nasopharynx affecting
primarily adolescent males. Its propensity to bleed
torrentially due to its highly vascular nature and its ability
to spread along the base of skull and intracranially, makes
it clinically a rather feared entity. Surgery is the preferred
mode of treatment, radiation being reserved for
unresectable intracranial tumors (Ungkanont K et al 1996).
The various surgical approaches that have been tried e.g.
transpalatal, lateral rhinotomy, Weber Fergusson, midfacial
degloving and the trans-zygomatic infratemporal approach
reflect clearly the technical difficulty in completely excising
all tumor extensions.
CASE REPORT
A 15-yr-old boy came with history of epistaxis and
blocking of the nose since 6 months. Clinical examination
revealed a mass in the nasopharynx and the right posterior
choana. A CT Scan was done which showed an
enhancing mass in the nasopharynx and in both choanae
with widening of the sphenopalatine foramen and
involvement of the infratemporal fossa medially (Fig. I &
II). A preoperative carotid angiography was done to
delineate the feeder vessels, which were then embolised
with gel foam. Complete disappearance of the tumor blush
indicated good devascularisation of the tumor (Fig III &
IV).
The patient was taken up for endoscopic excision after
48 hours. The tumor was excised completely
endoscopically using 0°, 30° and 70° endoscopes (Fig
V). A good bipolar cautery, upward and straight biting
forceps and periosteal dissectors of various sizes were
also required. The tumor was delivered transorally.
1Associate Professor & Head of ENT Dept, 2ENT Lecturer, 3ENT Lecturer, 4Adhoc ENT Lecturer, Dept. of ENT, L.T.M.M.College &
L.T.M.G.Hospital, Sion, Mumbai.

then finally dissecting them subperiosteally with a periosteal
elevator under direct vision. The sequence of visualization,
bipolar cauterization, and subperiosteal dissection has to
be meticulously and patiently repeated till all tumor
attachments have been dissected off and the entire tumor
is completely free from the surrounding tissues.
RESULTS
Our results in this case were very gratifying. The total
intraoperative blood loss in this case was 200cc. The patient
required no blood transfusion. Since the operative field
was bloodless, after complete tumor excision, no anterior
or posterior nasal packing was required. The raw area
was covered with antibiotic soaked gel foam alone. The
patient was monitored closely in the intensive care unit
for 24 hours following surgery. His postoperative course
was uneventful. Histopathology confirmed the diagnosis
of angiofibroma. He has remained free of recurrence 6
months postoperatively (Fig VII)
The second difficulty is in being able to visualize all the
tumor extensions detected on CT Scan (Lloyd DM et al
1999) even with angled telescopes. It may be necessary
to remove part of the middle turbinate, the medial and
posterior wall of the maxillary sinus and other similar bony
partitions so as to release the bottlenecking of the tumor
and visualize it completely (Fig VI).
DISCUSSION
With the evolution of endoscopic surgery, better
instrumentation and greater experience in the field, it is
now possible to view endoscopic excision of angiofibroma
as a viable alternative to open surgery.
The most significant advantage of this technique is that it
allows meticulous dissection of the tumor under direct
vision in the subperiosteal plane. This minimizes bleeding
making it possible to visualize all tumor extensions aim
remove them completely. With this technique, we therefore
hope to see a decrease in the recurrence rate (Herman P
et al 1999). There is also a significant decrease in the
postoperative morbidity as the patient requires no nasal
packing and is able to breathe, eat, and talk freely within
hours of surgery. The absence of any facial scar is also a
major advantage in young adolescent males.
There are two major difficulties that need to be effectively
solved before endoscopic excision is possible. First, the
bleeding has to be kept to the minimum to allow proper
visualization. This is ensured by preoperative embolisation
(Tranbahuy P et al, 1994). visualizing the attachments of
the tumor, cauterizing them with bipolar diathermy and

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REFERENCES
CONCLUSIONS
1. Herman P, Lot G, Chapot R et al (1999): Long term follow-up
of Juvenile Nasopharyngeal Angiofibromas: Analysis of
Recurrences. Laryngoscope 109: 140-147.
Even as the results of excision of JNA in this initial case
were highly gratifying, the true advantages, benefits and
limitations of this approach are becoming clear only as
we continue to do more cases endoscopically.
2. Lloyd DM, Howard D, Phelps P, Cheesman A (1999): Juvenile
Angiofibroma: the lessons of 20 years of modern imaging. The
Journal of Laryngology and Otology 113: 127-134.
We hope to see a significantly decreased patient morbidity
and a decrease in recurrence rates after auditing a greater
number of cases.
3. Tranbahuy P. Borsik M. Herman P. et al (1994): Direct
Intratumoral Embolisation of Juvenile Angiofibroma. American
Journal of Otolaryngology 15(6): 429-435.
4. Ungkanont K, Byers RM, Weber RS, Callender DL. Wolf PF,
Goepfert H (1996): Juvenile Nasopharyngeal Angiofibroma:
An Update of Therapeutic Management. Head Neck: 18( I);
60-66.
However this initial case does indicate that endoscopic
excision of JNA could be a viable, more precise and better
alternative to open surgery in selected tumors.
ACKNOWLEDGEMENTS
We are grateful to Dr. Uday Limaye and Dr. Kishor Rajpal Address for correspondence:
of the Depts. of Radiology of K.E.M Hospital & L.T.M.G.
Dr. R.A. Bradoo,
General Hospital respectively. We are also grateful to Dr Associate Professor & Head of ENT Dept,
(Mrs.) A. R. Fernandez, Dean, L.T. M. Medical College L.T.M.M.College & L.T.M.G.Hospital, Sion,
& General Hospital.
Mumbai 400 022