Journal Reading Double John

8/10/2019 Journal Reading Double John

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TUTOR :DR. TRIS SUDYARTONO, SP.THT-KLDR. AGUS SUDARWI, SP. THT-KLDR. SANTO PRANOWO, SP.THT-KL

Journal ReadingJuvenile Nasopharyngeal Angiofibroma :Current Treatment Modalities and Future

ConsiderationPresented by :

Jonathan Karel Gunawan(11.2013.132)

Ricky Johnatan

(11.2013.275)


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Introduction

Juvenille Nasopharyngeal Angiofibroma(JNA)is a benign, slowly growing, highlyvascular, and locally agressive vasoformativeneoplasm.

Presents most commonly in adolescentmales with a median age of 14 years.

The most common benign neoplasm ofnasopharynx, represents approximately0,5% of all head and neck tumors


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The tumor originates from the superior margin of

the spenopalatine foramen

These tumors are asymptomatic until theyincrease and encroach on critical structures

(cranial nerves, major vessels, the cavernous sinus,and dura).

Majority of these patients (75%) present withepistaxis and nasal obstruction, with symptomspresent from months to years.


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Most surgeons agree that surgery is the primarytreatment modality for the early stagedisease process.

However, controversy arises regarding the bestapproach to treatment when the patient present s

with more advanced disease (such as widespreadcranial base extension or intracranial involvement).


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In these dilemmas, a combination approach

inculding surgery followed by postoperative

radiation can be used, depending on the

clinical scenario.


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Chmielik et al. : an angioma with an extendedfibrous component.

Patients with JNA are typically silent

Often present with epistaxis, nasal obstruction,facial numbness, rhinorrhea, ear popping, sinusitis,cheek swelling, visual changes, and headaches.

Up to 1/3may present with proptosis or otherorbital involvement, which are late symptomsand findings.


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A polypoidal nasopharyngeal

angiofibroma occupying the nasalcavity


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Lateral growthput tumor in the pterygomaxillary fossa

Extension of tumor can erode the pterygoid process of the

sphenoid bone

Further lateral extension can fill the infratemporal fossa,producing classic bulging of the cheek


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Juvenille Angiofibroma Growth

Tumor can also extend under the zygomatic archwhichsubsequently causes swelling above the arch.

From the pterygomaxillary fossa, angifibroma can grow into theinferior and superior orbital fissues.

Tumor can extend extradurally in the middle fossa near oradjacent to the cavernous sinus.

Growth to posterior into the sphenoid sinus pushes upward andback to displace the pituitary and then can fill the sellatursica.


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Angiofibromas


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Bood Supply

The main blood supply is theinternal maxillary artery

Other vessels can inclucludethe dural, sphenoidal, andophthalmic branches of theinternal carotid system.


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Management of JNA

Management of JNA has become morerefined by more accurate diagnosticradiological tools (CT, MRI)

Improved embolization techniquespreoperatively have also contributed to thesuccessful management of JNA cases.

Technological innovations and increasedfamiliarity with skull base surgicalapproaches have facilitated themanagement of these tumors.


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Radiological Evaluation of JNA

CT was and is essential in determining theprecise location of the tumor.

Now MRI with and without gadolinium is theinitial diagnostic method of choice.

Flow voidsand marked gadoliniumenhancement of the mass is characteristicof JNA.


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Coronal view of MRIAxial section of CT scan


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Angiography and Embolization of

JNA Purpose: demarcate blood supply of

the tumor completely.

Polyvinyl alcohol (PVA) particles of theappropriate size (300-500 m) are

used to embolize major feeding

vessels.


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Selective left common carotid injectionshows hypervascular angiofibroma mainlysupplied by the internal maxillary artery

Postembolization arteriogram showsocclusion of left internal maxillary artery

and its branches supplying the tumor


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The surgical approach is determined

primarily on tumor location, extent and

surgical expertise

Surgical approaches can be Inferior, lateral

and anterior


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Anterior: transnasal, le fort I maxillotomy, medialmaxillotomy

Lateral : infratemporal fossa approach

Inferior : transpalatal, transoral-transpharyngeal(bestsuited for tumor localized in the nasal cavity andnasopharynx)


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Exposure of inferior aspect of the tumor in the pterygopalatine fossaafter excision of pterygoid plates


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Endoscopic Surgery for JNA Since advances in endoscopic technology,

endoscopic approaches are used as an adjunct

to combined approaches

Midili et al : Endoscopic transnasal approach

has advantages of no non-cosmetic sequela,less hemorrhage and no disruption in facialskeleton


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Ligation of the sphenopalatine artery


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Roger

4 patient stage I 7 patient stage II 9 patient stage

IIIA Residual : highly

vascular &extensive case

Hazarika et al

2 KTP/532

laser assisted 2 KTP/532

transpalatalapproach

Andrade et al

8 patient

stage I 4 patient

stage II 12 patient

raged from 9

to 22 yearsold withoutpreoperativeembolization


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ENDOSCOPY OPEN RESECTION

Mean Operative time 312

Interaoperative blood loss

509 cc Average lenght of hospital

stay 3 days

Mean Operative time 365

Interaoperative blood loss

934 cc Average lenght of hospital

stay 4 days

Based on this study, endoscopic resection of JNA was foundto be a safe and effective technique because of decreased

blood loss, shorter hospitalization, and lower recurrent rates

especially if tumors did not extend through intracranial space


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The combination of endoscopic and open

approaches for advanced tumors allows

better visualization of the lesion and

facilitates total removal


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Adunctive treatment with laser Using the KTP (potassium titanyl phosphate) laser,

Scholtz et al. reported decreased blood loss andreported 15% recurrence rate in his series

Mair et al : Nd Yag laser (4-10 watt) was found to beextremely useful in debulking the core of the mass

with no blood loss and in identifying the pedicle of themass, which could be endoscopically avulsed


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Patients with intracranial involvement,unresectable disease, religious preferences,or multiple recurrences may be good

candidates for radiation treatment

Conventional radiation treatment has side-effects such as osteoradionecrosis, abnormal

bone growth, panhypopituitarism, temporallobe necrosis, cataracts and radiationkeratopathy


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Liu et al. reported 2 patients with stage IVincompletely resected tumors who were given30 Gy and 40 Gy, respectively without

recurrent at 1 and 6 years

Newer techniques in radiotherapy treatment

such as intense-modulated conformalradiotherapy (IMRT) and gamma knife havegreat potential for future management of JNA


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Conclusion

Because of technological advances both insurgery and radiology, management of JNApatients has been refined

Surgery still remains the preferred treatmentfor these vascular tumors. Radiation isreserved for cases when surgery iscontraindicated and rarely is ndicated as a

primary source of treatment


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Endoscopic surgery is rapidly becoming the

method of choice and eventually may be

replaced with robotic surgery which is in its

infancy for treatment of skull base tumors.

Finally, image-guided robotic radiotherapy

could also be included in the future


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