TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.
Explore this issue:November 2016
Juvenile nasopharyngeal angiofibromas (JNAs) are rare, slow-growing tumors of the nasal cavity and skull base that account for approximately 0.5% of all head and neck tumors. This benign, highly vascular tumor is almost exclusively found in adolescent males. JNAs classically present with nasal obstruction and/or recurrent epistaxis. More advanced tumors can present with facial asymmetry, facial swelling, and visual disturbances. Histologically, JNAs are nonencapsulated tumors comprised of an irregular network of blood vessels set in fibroblastic stroma. They are thought to originate from the sphenopalatine foramen and initially grow into the nasal cavity and pterygopalatine fossa. More advanced lesions are locally destructive and can extend into the infratemporal fossa, orbit, and middle cranial fossa. There are a number of staging systems for JNAs based on the size and extent of the tumor; however, there is no current consensus regarding the optimal classification. The treatment of JNAs is surgical excision, often in combination with preoperative angiography and embolization of the vessels supplying the tumor. JNAs were traditionally resected via open surgical approaches; however, with the advancement of endoscopic skull base techniques, an increasing number of these tumors are being removed endoscopically.
The question as to whether there is an optimal surgical approach for the resection of JNAs continues to be a source of controversy. There is a growing body of evidence supporting, at the very least, the equivalence of endoscopic and open surgical approaches in terms of tumor recurrence. It does appear that the endoscopic approach, either alone or in combination with preoperative embolization, has less intraoperative blood loss. The findings from the systematic reviews, though informative, highlight the need for prospective multi-institutional trials, which employ validated tumor staging systems and clinical outcome measures. Although great strides have been made regarding evidence-based management of JNAs, the extent and location of the tumor, combined with the surgeon’s judgment and skills, should ultimately determine the optimal approach for each patient (Laryngoscope. 2015;125:2436–2437).