Endoscopic surgery for juvenile angiofibroma: a critical review of indications after 46 cases.

Background: At present, transnasal endoscopic surgery is considered a viable option in the management of small-intermediate size juvenile angiofibromas (JAs). The authors critically review their 14-year experience in the management of this lesion to refine selection criteria for an endoscopic approach.
Methods: From January 1994 to May 2008, 46 patients were treated by a pure endoscopic resection after vascular embolization (87%). The lesions were classified according to Andrews (Andrews JC, et al., The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach, Laryngoscope 99:429-437, 1989) and Onerci (Onerci M, et al. Juvenile nasopharyngeal angiofibroma: A revised staging system, Rhinology 44:39-45, 2006) staging systems. All patients were followed by regular endoscopic and magnetic resonance imaging (MRI) examinations.
Results: Lesions were classified as follows: stage I, n = 5; stage II, n = 24; stage IIIa, n = 14; stage IIIb, n = 3 according to Andrews classification system; stage 1, n = 9; stage II, n = 12; stage III, n = 26 according to Onerci's system. Unilateral blood supply was detected in 39 (85%) cases. Feeding vessels from the internal carotid artery (ICA) were also reported in 14 (30%) patients. Intraoperative blood loss ranged from 250 to 1300 mL (mean, 580 mL). In four (8.7%) cases, suspicious residual disease was detected by MRI. In one patient, a 1-cm persistent lesion was endoscopically removed because septoplasty was required and a slight increase in size was noticed. The other three lesions, all located in the root of the pterygoid plate, are nearly stable in size and are currently under MRI follow-up.
Conclusion: The improvement of surgical instrumentation and the experience acquired during a 14-year period have contributed to expanding the indications for endoscopic surgery in the management of JAs. Even stage III lesions may be successfully managed, unless the ICA is encased or if it provides an extensive blood supply. An external approach may be required when critical structures such as the ICA, cavernous sinus, or optic nerve are involved by lesions that are persistent after previous treatment; such a situation may prevent safe and radical dissection with a pure endoscopic approach. Better understanding of the factors influencing the growth of residual lesions is needed to differentiate those requiring re-treatment from those which can be simply observed.