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From 1977 to 2001, 5 patients were seen with giant angiofibromas that had intracranial penetration. Three of these had involvement of the cavernous sinus with angiographic evidence of significant blood supply to the tumor. We attempted complete tumor removal in all patients via a skull-base procedure. The infratemporal fossa/middle fossa approach was used in 3 patients, an anterior craniofacial approach in 1, and an anterior subcranial approach in 1. Complete tumor removal was achieved in 4 patients and incomplete excision in 1. The latter was attempted with an anterior subcranial approach but required an infratemporal fossa/middle fossa approach for completion because of unanticipated cavernous sinus involvement. The patient declined further surgery. This was the only patient who had persistent disease. Preoperative and intraoperative management, blood loss, complications, and residual effects are described.

Background Juvenile nasopharyngeal angiofibromas (JNAs) are highly vascular tumors that originate in the nasopharynx of young males. The primary treatment is surgical excision. Traditional surgical approaches are associated with significant morbidity and facial deformity. We introduce and outline the clinical advantages of an endoscopic surgical approach to JNAs using the Nd:YAG laser with image-guided surgery. Design Case series. Setting Tertiary care medical center. Patients and Methods Our study included 5 male patients (age range, 8-21 years) with extensive JNAs. Their tumors were large and ranged from Fisch stage IIA to IIIA. Embolization of tumor-feeding vessels was performed before surgery. The tumors were photocoagulated via a transnasal endoscopic approach using a Nd:YAG laser. Devascularized, lased tumor was removed with a microdebrider. Image-guided navigation systems were used to assist skull base tumor removal, and sublabial and buccolabial incisions were used as needed to gain lateral endoscopic tumor access. Endoscopic tumor margins were obtained for frozen section. Results All patients achieved symptomatic remission, with no complications. No blood transfusions were necessary. The patients were ready for discharge 1 to 2 days after surgery. Postoperative and magnetic resonance imaging scans showed 2 skull base recurrences, which were removed endoscopically. Follow-up ranged between 2 and 3 years. Conclusions Traditional external surgical approaches to large JNAs may result in significant morbidity. Laser-assisted image-guided endoscopic excision of JNAs is a safe and effective minimally invasive surgical treatment. Its distinct advantages include (1) diminished blood loss, (2) superior cosmesis without observed altered facial growth, (3) direct access of skull base with minimal morbidity, and (4) ease of endoscopic follow-up.

Angiofibromas occur commonly as solitary le­ sions (fibrous papules) on the face of adults, and they also appear extensively on patients with tuberous sclerosis. Fibrous papules are generally smooth, firm, dome-shaped, and skin colored, but they may have a rim of erythema or be slightly pigmented. Although many authors believe that fibrous papules and angiofibromas are identical, others classify them individually.' Angiofibromasoccurinapproximately 90% ofpatients with tuberous sclerosis and are vari­ ably colored, reflecting the amount ofvascular ecta­ SIa. Angiofibromas contain a variable number of spindle-shaped stellate fibroblasts in the papillary dermis and increased numbers of blood vessels that are frequently dilated. 1 The cause of these angiofi­

We retrospectively analyzed the clinical data of 21 patients (22 procedures) with histologically proven nasopharyngeal angiofibromas. Eleven patients underwent preoperative intra-arterial digital subtraction angiography (IADSA) and embolization with Gelfoam. Embolization reduced the intraoperative blood loss from an average of 1136 ml in the non-embolized patients to 677 ml in the embolized cases (P < 0.05) and transfusions from an average of 836 ml to 400 ml (P < 0.01). Results again show that preoperative embolization is effective in reducing intraoperative blood loss.

Objective: To evaluate patients with multiple endocrine neoplasia type 1 (MEN1) for cutaneous manifestations. Design: Survey during a 3-year period. Setting: The National Institutes of Health, a tertiary referral research hospital in Bethesda, Md. Patients: A consecutive sample of 32 individuals with previously diagnosed MEN1 who were not preselected for the presence of skin lesions were examined for cutaneous abnormalities. None of the patients or family members were diagnosed as having tuberous sclerosis. Interventions: Lesions were identified by clinical appearance, photographed, and confirmed histologically. Main Outcome Measure: To determine the frequency of skin lesions in patients with MEN1. Results: Multiple facial angiofibromas were observed in 28 (88%) of the patients with MEN1, with 16 patients (50%) having 5 or more. Angiofibromas were clinically and histologically identical to those in individuals with tuberous sclerosis. Collagenomas were observed in 23 patients (72%). Also observed were cafe au lait macules in 12 patients (38%), lipomas in 11 patients (34%), confettilike hypopigmented macules in 2 patients (6%), and multiple gingival papules in 2 patients (6%). Conclusions: Multiple angiofibromas, collagenomas, lipomas, confetti-like hypopigmented macules, and multiple gingival papules are cutaneous manifestations of MEN1 and should be looked for in both family members of patients with MEN1 and individuals with hyperparathyroidism or other MEN1-associated tumors. Multiple angiofibromas can no longer be considered pathognomonic for tuberous sclerosis. The observation of angiofibromas in individuals without tuberous sclerosis necessitates further biochemical testing for MEN1. Arch Dermatol. 1997;133:853-857

Our experience with the use of systemic chemotherapy in the management of locally aggressive head and neck tumors in the pediatric age group (desmoid fibromatosis and nasopharyngeal angiofibroma) is presented. Objective decreases in the size of tumors was found in all patients with desmoid fibromatosis was treated with chemotherapy before definitive surgical resection was performed. The changes noticed on examination correlated with the histologic and radiologic findings. Two patients with recurrent juvenile nasopharyngeal angiofibromas showed striking therapeutic improvement in their residual tumor mass as witnessed by radiographic studies and biopsies. Toxicity and side effects of the treatment are discussed.

Juvenile nasopharyngeal angiofibromas (JNA) are rare. They have been frequently treated with estrogens, either solely or as an adjuvant therapy prior to surgery or irradiation. Clinical trials have provided no evidence to explain the objective response to estrogens observed in some tumors. Since the mechanism of steroid hormone action is mediated via specific receptors, we analyzed 8 JNA for tumor cytosol estrogen receptors. None were positive for estrogen receptors. Additionally, all were also negative for progesterone receptors. Nasopharyngeal angiofibromas occur predominantly in adolescent boys at a time when there is a gradual change in androgen availability. Therefore, three latter angiofibromas were also analyzed for the presence of cytosol androgen receptor. Specific testosterone and dihydrotestosterone binding components in the tumor cytosol were detected. This observation raises for the first time the possibility that JNA may be an androgen-dependent tumor. Estrogen may act as an antiandrogen on these tumors, an action similar to that on prostate cancer. Cancer 46:547–551, 1980.

A case of a juvenile nasopharyngeal angiofibroma is reported. The bilateral selective angiograms of the external carotid arteries as well as of the internal carotid arteries revealed a distinct tumor stain. The importance of selective angiography in cases of surmised juvenile nasopharyngeal angiofibromas is emphasized, since this examination makes it possible for one to determine not only the extent and the vascular supply, but in most cases also the specific diagnosis of the tumor.

Angiofibromas are histologically benign tumors occurring in young men;however, they are frequently managed as malignant tumors because of their locally expansive nature, high vascularity and tendency to recur. In the majority of cases, they are attached to the roof or the posterior wall of the nasopharynx.Recently, we have treated a patient with an extremely rare type of angiofibroma which was attached to the posterior edge of the vomer. There are few reports of this tumor occurring in the perichondrium of the vomer of the nasal septum. A 16-yearold male had an angiofibroma of the nasal septum. After selective embolization of both sphenopalatine arteries, the tumor was completely removed through a palatine approach.

Port wine stains (PWSs), hereditary hemorrhagic telangiectasias (HHTs), hemangiomas, arterial venous malformations (AVMs), vascular granulomas and polyps, glomus tumors, and nasopharyngeal angiofibromas are vascular lesions of the head and neck potentially responsive to treatment with the argon laser. One hundred consecutive patients with PWSs, 25 patients with HHTs, three with subglottic hemangiomas, three with oral and/or lingual hemangiomas, two with labial AVMs, three with vascular laryngeal polyps, and one patient with inoperable glomus tumor were treated with the argon laser. Results were good to excellent in 94% of the facial PWS patients. All treated patients in the HHT group demonstrated improvement. Results with the other lesions were variable. The argon laser is a valuable treatment modality in vascular lesions of the head and neck. Posttreatment scarring and failure to achieve desired results are complications encountered. Pretreatment counseling will assist the patient in understanding the expected results.

A new case of Goltz's syndrome, focal dermal hypoplasia, is documented. The literature is reviewed. The composite individuality warrants considering Golt'z syndrome a separate syndrome in the ectodermal dysplasias. Caution against diagnosing "condyloma-like" lesions occurring in ectodermally dysplastic patients as condyloma acuminatum is urged. Neoplastic transformation and the tendency to recurrence after surgical exicision of the cutaneous angiofibromas pose a difficult problem in surgical management.

Large juvenile nasopharyngeal angiofibromas are a therapeutic challenge because of their relation to major vasculature and cranial nerves at the base of the skull, and their propensity for recurrence. A classification scheme based on the growth pattern of this tumor is proposed to help the surgeon choose a procedure to access this lesion. This report describes the results obtained with the surgical removal of large (class III and IV) nasopharyngeal angiofibromas through the infratemporal fossa approach. Fourteen patients were cured and one individual developed a recurrence which was totally removed at a second procedure. Surgical morbidity was minimal and there was no mortality. Radiation therapy was necessary in only one patient who had tumor infiltration of the cavernous sinus.

An electron-microscopic study of 9 nasopharyngeal angiofibromas was performed in order to elucidate the ultrastructural characteristics. Stromal fibroblasts and proliferating cells of the microvasculature were found. The stromal fibroblasts were subdivided into 3 different groups: (1) "classical" fibroblasts, (2) fibroblasts with histiocytelike features, and (3) fibroblasts with myoid features. By proliferation the cells of the capillary vessels change into stromal cells. A particular pattern of nuclei and dense intranuclear granules is only found in stromal fibroblasts. Consequently fibroblasts as well as cells of the microvasculature contribute to the pool of tumor cells.

After the electron miscroscopic examination of tissue samples of juvenile nasopharyngeal angiofibromas obtained from 9 male patients ranging in their age from 7-24 years the problems of cytogenesis and classification are discussed. Besides it is tried to correlate particular morphological findings to certain clinical phenomenons. The vascular component of juvenile nasopharyngeal angiofibromas shows a clear proliferation of the vascular wall cells. Particularly, proliferating pericytes, cells withous peculiar characteristics ("undifferentiated" cells) and cells in various stages of differentiation are to be emphasized. Obviously, vascular wall cells emigrate into the surrounding tissue and transform themselves into small fibroblasts. The second component of juvenil nasopharyngeal angiofibromas is represented by stromal fibroblasts with several cytological variations. Only activated "classical" fibroblasts and fibroblasts with histocyte-like features reveal the nuclear pattern unique for these growths which is characterized by the combination of protrusions of nuclear membrane with formation of nuclear "blebs" and of dense intranuclear granules. Cells with these nuclear characteristics were considered as preexisting fibroblasts. Thus juvenile nasopharyngeal angiofibromas are formed by the proliferation of two tissue components, namely by the proliferation of vascular wall cells and stromal fibroblasts, and can be conceived as reactive hyperplasias. The swelling body-like and organoid appearance, cytological pecularities, characteristic topographic relations (localization and supplying vessesl) and the sex-dependent occurrence speak for a tumor-like hyperplasia of a rudimentary organ unknown till now.

Juvenile angiofibromas (JAF) and angiomatous polyps (AP) are vascular histologically benign tumors presenting with an identical clinical triad. Both lesions can be differentiated by their typical geographic pattern of growth, different pattern of tumor extension and their highly characteristic angiographic and angiocomputertomographic appearance. Time-density curves were of no use in differentiating the big variety of hypervascular lesions from each other. CT images of the vascular tumor phase after bolus injection of contrast medium however showed interesting pathomorphological details, which were extremely useful in differentiating JAF from AP and other vascular tumors. It is our opinion, that invasive angiography for diagnosing JAF has been surpassed, but is further essential for mapping of tumor perfusion, feeding vessels and praeoperative embolization therapy.

A systematic approach to the diagnosis and treatment of angiofibromas is presented. The distinction between true and false internal carotid supply to these tumors as well as identification of vascular anatomical variants that may represent potential hazards of embolization are emphasized. Areterial supply to the cranial nerves, prevention of neurologic complications, and the use of inappropriate embolization materials are also discussed.

Computerized axial tomography (CAT) of the head provides the otolaryngologist with an effective diagnostic tool. This technique is particularly useful when used in the preoperative evaluation of head and neck pathology and may be used to define the extent of disease and to direct the surgical approach. The case of a 16-year-old male with an extensive angiofibroma involving the paranasal sinuses and nasopharynx is presented as an example of CAT in preoperative planning of the surgical procedure. Computerized tomography was used initially to define the tumor margins. Serial CAT scans were also obtained at intervals during the patient's preoperative estrogen therapy. Evidence was obtained which suggests CAT may be used to monitor the effects of preoperative hormone management of angiofibromas and in the definition of the optimal time for surgery. In the case presented the final CAT scan provided a detailed and accurate description of the tumor margins which were confirmed at surgery. Our experience with a case of an extensive nasopharyngeal angiofibroma demonstrates the CAT scan to be a useful objective diagnostic method for preoperative planning.

The juvenile nasopharyngeal angiofibroma, a rare neoplasm of adolescent males, is histologically benign but often clinically malignant. Although spontaneous regression of this tumour has been reported (Dane, 1954; Martin, Erhlich and Abels, 1948), this is not the usual clinical course and aggressive treatment is necessary to control symptomatic lesions. Surgical resection has been generally regarded to be the treatment of choice (Pressman, 1962; Rodriguez, 1966, English, Hemenway and Cundy, 1972). However, it has been our experience (Kadin, 1974), as well as that of others (Patterson, 1965), that results of attempted resection of angiofibromas which have extended widely beyond the nasopharynx have been poor. Because of this experience, a patient with an extensive nasopharyngeal angiofibroma was treated with radiation therapy with pre-and post-arteriographic studies to evaluate the extent of the tumour and the results of therapy. A 14-year-old Japanese-American male presented with a four-month history of n...

The gross amount of bleeding during surgical removal of nasopharyngeal angiofibromas is feared. An excellent method to reduce this amount is the preoperative selective embolization of the feeding vessels of these tumors under angiographic control. The advances in selective angiography of the branches of the external carotid artery by femoral catheterization make it possible to applicate Gelfoam emboli in the very arteries which are to be embolized. There is a case report about two young men who have been pretreated in this manner. The intraoperative bleeding was minimal.

Facial angiofibromas are estimated to occur in 90% of patients with tuberous sclerosis and can cause considerable cosmetic disfigurement, emotional distress, obstruction of vision, and hemorrhage when abraded. Postoperative wound management associated with skin grafting and dermabrasion is often difficult because patients are mentally retarded and noncooperative. Three patients with extensive facial angiofibromas were treated successfully with the carbon dioxide (CO2) laser, with follow-up period ranging from 8 to 48 months. Uncomplicated wound healing occurred in each patient with minimal recurrence of lesions. Ablation with the CO2 laser is our treatment of choice for angiofibromas associated with tuberous sclerosis.

During a nine year period fifty nasopharyngeal angiofibromas thirteen of whom had recurrent tumour were treated surgically. Thirty-one patients in whom the tumour was limited to the nasopharynx or those with superior spread into ethmoids or sphenoid sinuses were removed by a transpalatal route alone or in combination with other approaches. Tumours having lateral extensions into pterygopalatine or infratemporal fossae or the cheek, or those with simultaneous superior and lateral spread underwent a transmaxillary excision. In two of the three cases having intracranial spread the tumour was removed successfully from below. There was no mortality. The usefulness and versatility of the transmaxillary approach in extensive and recurrent cases is emphasised. Computerized tomography was found to be a vital adjunct in pre-operative evaluation. The pros and cons of other approaches are also briefly discussed.

Angiofibromas of the nasopharynx are known to have ocular involvement usually as a late manifestation. Absence of nasal symptoms for a considerable period, even up to 6-12 months after the initial ophthalmic complaints, is unusual and has not been reported before in the literature. A series of cases including nasopharyngeal angiofibroma and nasopharyngeal carcinoma are presented. Various ocular manifestations included proptosis, papilloedema, optic atrophy and cranial nerve palsies. Confirmation of diagnosis required a thorough ENT cheekup, like skiagraphy, computerized tomography, carotid angiography and ultrasonography. In two cases of angiofibroma, massive extension of the tumour was noted intracranially without any other obvious neurological or otolaryngological complaints. Other extremely rare features included occurrence of angiofibroma in a 29-year-old female.This communication highlights the importance of such unusual modes of presentation and the necessity of a detailed ENT check-up as well as ot...

Intra-arterial embolisation is a valuable adjunct to the treatment of many vascular lesions, including neoplasms such as glomus tumours or juvenile angiofibromas, and arteriovenous malformations. Its place in the management of the individual patient should be established before any surgical procedure is carried out, as this may prejudice the eventual result. The indications for the procedure, the technique, and possible complications are discussed in this paper, and it is emphasised that the latter are best avoided by the use of a scrupulous technique and adequate technical facilities.

Therapeutic embolization of juvenile angiofibromas was performed in 15 boys, aged 12--18 years, 11 of whom subsequently underwent surgery. Intraoperative blood loss was reduced from an average of 2,400 ml in nonembolized patients to 800 ml after embolization. Angiography is of value to confirm the diagnosis prior to excision and to delineate the extent of the tumor. Embolization may be performed at the same sitting as a presurgical adjunct or possibly as a definitive or palliative therapeutic method. The embolization procedure is discussed in detail, emphasizing techniques and potential hazards of such procedures.

57Co-Bleomycin (57Co-BLM) was used to visualize malignancies of the head and neck because it does not present the disadvantages of many other radiopharmaceuticals. In a series of 21 patients with 9 control subjects and 12 cases of tumors. 57Co-BLM showed a high and rapid uptake in primary site and metastases of malignant tumors of various histologic types, but not in benign tumors such as angiofibromas. Compared to 67Ga-citrate. 57Co-BLM has many advantages for tumor imaging in the areas of nose, pharynx and larynx: No background activity due to the concentration of 57Co-BLM in normal structures of the head and neck has ever been observed, as opposed to what happens with 67Ga-citrate. Furthermore, the blood clearance of 57Co-BLM is much more rapid than that of 67Ga-citrate, so that an early study may be performed in a 6-24 hr. interval instead of 48-72 hr. with 67Ga-citrate. 57Co-BLM scintigraphy is an easy, non-invasive and sensible diagnostic technique in determining the extent of malignant tumors in ORL patients.

The authors had the chance of treating two cases of rhinopharyngeal angiofibroma before the age of puberty, and were thus stimulated to re-examine the incidence of such neoplasms in the pediatric age group, i.e. under 12 years of age. From their clinical statistical studies, and in the light of their personal experience, they were able to make the following observations. 12.9% of angiofibromas occur by the age of 12 years. These tumours present a shorter period of symptomatological evidence with respect to those which occur later. They are histologically characterized by a greater richness of cellular and vascular components with respect to those of a fibrous nature. Among the equipment used in radiology, computerized axial tomography showed itself extremely useful. The paralateronasal path is the most commonly used among surgical paths, as it is able to throw more light on tumour. The frequency with which the neoplastic mass relapses during operation is proportionally greater the earlier the primitive tumour occurs.

summary Collagen synthesis and the ratios of collagen types I and III were assayed from the skin lesions of five subjects with tuberous sclerosis. Collagen synthesis, measured by the activities of prolyl hydroxylase and galactosylhydroxylysyl glucosyltransferase, was clearly increased in three angiofibromas of these patients and in one soft tumour of the face, but it was unchanged in shagreen patches. The total collagen content was decreased in angiofibromas, indicating either increased turnover of collagen or an increased amount of cellular or other macromolecular elements in these lesions. The proportions of types I and III collagens, estimated by cyanogenbromide digestion and SDS-gel electrophoresis, were 80–90% and 10–20%, respectively, in all samples except two angiofibromas, in which the relative amount of type III collagen was increased. This may indicate that angiofibromas of tuberous sclerosis are heterogenous with respect to the collagen types they contain, and that there may be disturbed cell growth or collagen synthesis, with individual variation from case to case.

Angiofibromas occur in 90% of patients with tuberous sclerosis. Their growth is slowly progressive until adult life, causing considerable cosmetic disfigurement and severe emotional and psychological problems. Dermabrasion can be used successfully to improve cosmesis and hence the quality of life in such patients.

• Five patients with recurrent juvenile nasopharyngeal angiofibromas were treated with antineoplastic chemotherapy. All patients had tumor remission without recurrence; there were no sequelae after this therapy. ( Arch Otolaryngol 1985;111:285-289)

In a nine-year period 50 nasopharyngeal angiofibromas, of whom 13 had recurrent tumour, were treated surgically at the All India Institute of Medical Sciences, New Delhi. A new staging system according to the regions involved was used; 31 patients in whom the tumour was limited to the nasopharynx (Stage I) and those with superior spread into the ethmoid or sphenoid sinuses (Stage IIA) had their tumours removed by a transpalatal route, alone or in combination with other approaches. Tumours with lateral extensions into the pterygopalatine or infratemporal fossae or the cheek (Stage IIB), and those with simultaneous superior and lateral spread (Stage HI) underwent a transmaxillary excision (19 cases). In two of the three cases with intracranial extension (Stage IV), the tumour was removed successfully from below. There was no mortality. The usefulness of the transmaxillary approach, especially in recurrent cases, is emphasized. No adjuvant modalities were employed in this series and blood loss was acceptable.

We propose a system for staging nasopharyngeal angiofibromas based on clinical evaluation and computerized tomography. Twenty-three patients with this pathologic diagnosis have been managed at the University of Miami/Jackson Memorial Medical Center in the past two decades. In 13 patients, the clinical diagnosis was confirmed by transnasal biopsy as a minor outpatient procedure. This avoided unnecessary diagnostic studies, shortened the hospital stay, and expedited treatment. Computerized tomography has replaced conventional x-ray studies and routine tomography, although angiography is still necessary for proper evaluation of larger tumors. Stage groupings recommended on the basis of this experience are stage I — tumor confined to nasopharynx; stage II — tumor extending into nasal cavity and/or sphenoid sinus; stage III — tumor extending into one or more of the following: antrum, ethmoid sinus, pterygomaxillary and infratemporal fossae, orbit, and/or cheek; and stage IV — tumor extending into cranial cavity. Surgical excision is recommended for stages I, II, and III. Stage IV tumors require surgical resection and/or radiation therapy with the possible addition of hormonal therapy.

Twelve juvenile angiofibromas of the paranasal sinuses are described which were partly supplied by branches of the internal carotid artery. Five vessels were found to be involved; with increasing frequency they were: the middle cerebral artery, the dorsal meningeal artery, the ethmoidal arteries, the artery of the inferior cavernous sinus and the artery of the pterigoid canal. Intracranial extension of tumour occurred only once, but the paranasal sinuses were involved in all cases. Occasionally, early filling of veins was seen. The branches of the internal carotid artery played a small part in the arterial supply when compared with branches of the external carotid artery. In spite of this, up to 80% of the tumour could be opacified through internal branches. Bilateral internal artery supply stresses the necessity for selective demonstration of both internal and both external carotid arteries.

The distribution of collagen types in angiofibroma and shagreen patch from patients with tuberous sclerosis was examined biochemically and immunohistochemically by indirect immunofluorescence microscopy using type-specific anti-collagen antibodies. Types I and III collagens were distributed in the interstitium of whole tumor tissues of angiofibriomas and a shagreen patch, showing relatively fine fibers at the periphery and large bundles in the center. No significant difference in the distribution of type I and III collagens was observed. Densitometric analysis of gel electrophoresis patterns of collagens solubilized from the skin by limited pepsin digestion revealed that both type I and III collagens were the main constituents of the diseased regions of the skin with tuberous sclerosis, and the ratio of type I collagen/type III collagen was relatively constant, which was not contradictory to the results of immunofluorescence microscopy. The presence of an unidentified component, probably type V collagen, was observed in the angiofibroma tissue from one patient with tuberous sclerosis.

A systematic treatment approach for nasopharyngeal angiofibromas is presented. Surgery, as the primary treatment modality is advocated. Routine pre-operative angiography is utilized for diagnosis and delineation of tumor extent. The surgical approach or approaches is dependent upon the tumor extent.

Images Figs. 4-5 Figs. 1-3

NOSE Carco 1 reported four cases of angiofibroma of the posterior end of the inferior turbinate bone. He discussed the pathology of nasal growths and expressed the belief that instead of being classified indifferently as bleeding polyps, the various types should be differentiated according to their microscopic structure. He believed his cases to be unusual, as he stated that most angiofibromas originate in the septum and anterior portion of the nose. Guthrie and Dott 2 reported two interesting cases showing the occurrence of brain tissue within the nose. The first case was that of a cerebral frontal glioma which penetrated secondarily into the nasal cavity, and the second was of a nasal polyp which showed neoplastic brain tissue on microscopic examination. These authors were not able to find in the literature reports of cases similar to the first one reported. Cases of the second type are not nearly

Juvenile nasopharyngeal fibromas are rare and benign. There would be no need to discuss them again were it not for the fact that they produce such alarming symptoms and present such serious problems in treatment. Injudicious surgical or radiologic treatment of such lesions can cause frightening hemorrhages, intracranial disturbances, and even death. The mere removal of a small piece of tissue from this type of lesion for microscopic examination occasionally can produce bleeding so profuse that ligation of the external carotid artery and the administration of blood are necessary. These tumors often are referred to as "nasopharyngeal angiofibromas," which is a good term in view of the fact that the vascular elements in many of these neoplasms are more prominent than the fibrous component. Juvenile fibromas arise from the base of the skull and are attached to the vault of the nasopharynx, usually by a broad, sessile base. Although they

At the 1963 meeting seven nasopharyngeal angiofibromas were reported from the endocrinological point of view. Four cases out of seven were followed for five years. Recent investigations of their hormone metabolites revealed that in the tumor-free cases the hormone-metabolite titrations had improved. In cases with the tumor still present, findings were the same as at the beginning.