Critical appraisal and the surgical technique of maxillary swing approach for advance stage juvenile nasopharyngeal angiofibroma

Unsuspected tumor extension in an occult anatomical region of nasopharynx with overwhelming surgical hazard and unpredictable outcome of surgical extirpation has made juvenile nasopharyngeal angiofibroma a unique experience for operating surgeons. This is more true for those advance tumors invading the skull base. No ideal surgical technique has been described to totally ablate these tumors, however, key to success in controlling the recurrence is the selection of surgical approach, which is tailored to the individual need and tumor staging. A variety of anterior and lateral skull base approaches have been described for advance stage III and IV nasopharyngeal angiofibroma. Maxillary swing approach was employed in five cases of juvenile angiofibroma in the present study, which, aims at evaluation of operative procedure in adolescents with respect to adequacy of exposure, peroperative difficulties, postoperative complications and the outcome in minimizing the rate of recurrences with this procedure. A total of 30 cases of JNA were done through various surgical procedures, inclusive of 5 maxillary swing approaches. The outcome was compared after meticulous follow up to identify any residual tumor or recurrences during next three years. The result showed that the procedures done through other surgical approaches in 30 cases required further surgical management for recurrences in 5 cases compared to 1 case in maxillary swing group. Most of these cases were re-explored through a transpalatal approach

Appraisal of clinical profile and management of juvenile nasopharyngeal angiofibroma in Malaysia

Juvenile nasopharyngeal angiofibroma (JNA) is a benign but locally invasive tumour. Patients are usually in their adolescent age and present with epistaxis and nasal blockage. Diagnosis is based on clinical evaluation and the C.T. scan findings. Pre-operative superselective embolisation (SSE) and surgical excision is the treatment of choice. The outpatient clinic of ORL-HNS hospital of University Science Malaysia received 25 referrals, all male, majority between 9-13 years of age and few adolescents. Clinically the patients were consistent with symptoms of recurrent epistaxis and nasal blockage. They reported from October 1998 to October 2001 from within the state of Kelantan and the nearby states of Pahang, Kedah and Terenganu. Diagnosis was mostly made on typical radiological findings and the tumours were classified accordingly into four stages. SSE and surgical excision was carried out in all cases. Regular follow-up helped us to identify early recurrences which were treated with salvage surgery or radiotherapy in one case with extensive intracranial extension. A retrospective review of presenting features, diagnostic difficulties, surgical approaches and its outcome is presented. Maxillary swing procedure performed in three cases as a new surgical option in the management of JNA is also discussed.