Transcript Nasopharyngeal angiofibroma - The Medical Post | Trusting

Nasopharyngeal
Angiofibroma
Dr. Vishal Sharma
Definition
• Benign tumor of nasopharynx (?), locally
invasive, extremely vascular & occurs in
adolescent males.
• Hamartomatous nidus of vascular tissue,
dependent on testosterone.
• Synonyms: nasopharyngeal fibroma,
angiofibroma
Site of origin
Arises in posterior nasal cavity, near superior
border of sphenopalatine foramen
Sphenopalatine foramen
Pathology
Gross: Sessile, bi-lobed, rubbery, red-pink or
gray in colour.
Histology: Encapsulated, composed of vascular
tissue & fibrous stroma. Vessels are thin-walled,
lack elastic fibers & smooth muscle (this leads
to uncontrolled bleeding).
Histopathology
Small tumour
Nasal cavity
Nasal cavity & P.N.S.
Nasopharynx
Pterygopalatine fossa
Infratemporal fossa
Infratemporal fossa
Cheek
Orbit
Sphenoid sinus
Middle cranial fossa
Pituitary & Cavernous sinus
Spread
Anterior: Nasal cavity + paranasal sinus
Posterior: Nasopharynx
Lateral: goes to Pterygopalatine fossa 
1. Infratemporal fossa  cheek
2. Inferior orbital fissure  orbit
Spread
Superior: 1. Sphenoid sinus
 Middle cranial fossa
 Cavernous sinus
 Optic chiasma
 Pituitary fossa
2. Skull base
 Middle cranial fossa
Symptoms
1. Nasal obstruction (80-90%) with denasal
speech (rhinolalia clausa)
2. Epistaxis (50-60%): Persistent, Painless,
Profuse, Paroxysmal, Unprovoked
3. Headache (25%)
4. Facial swelling (20%): cheek & palatal swelling
Facial swelling
Signs
1. Nasal or Nasopharyngeal mass (80%)
2. Frog-face deformity:
proptosis + nasal
bridge broadening
3. Otitis media with effusion:
due to E.T. blockage
4. Trismus: involvement of pterygoid muscle
5. Involvement of II, III, IV, VI cranial nerve
C.T. scan P.N.S. with contrast
• Extent of tumor
• Anterior bowing of
posterior maxillary
wall (Miller Holman’s
antral sign)
• Tumor enhancement
• Bone destruction
Other Investigations
 M.R.I.: for intra-cranial involvement
 Digital Subtraction Angiography (D.S.A.):
a. extent of tumor
b. tumour blush (due to increased vascularity)
c. feeding arteries for embolization
 Biopsy: contraindicated (profuse bleeding)
Magnetic Resonance Imaging
D.S.A. before embolization
D.S.A. after embolization
Differential diagnosis
• Rhabdomyosarcoma
• Antrochoanal polyp
• Teratoma
• Dermoid
• Encephalocoele
• Inverting papilloma
• Squamous cell carcinoma
Staging
Stage I: Tumor limited to nasal cavity or
nasopharynx with no bony destruction
Stage II: Tumor invading pterygopalatine
fossa or paranasal sinuses
Stage III: Tumor invading infratemporal
fossa or orbit or parasellar region
Stage IV: Tumor invading cavernous sinus
or optic chiasma or pituitary fossa
Pre-op reduction of tumor
vascularity
1. Embolization of feeding arteries: with Gelfoam
2. Oestrogen therapy: Diethylstilbestrol (2.5 - 5
mg orally t.i.d. for 3 - 6 wk)
3. Testosterone receptor blocker: Flutamide
4. Pre-operative radiotherapy
5. Cryotherapy of tumor
Trans-palatal approach
Trans-palatal approach
Trans-palatal approach
Sardana’s approach
Endoscopic approach
Lateral rhinotomy approach
Lateral rhinotomy approach
Midfacial degloving
Denker’s incision
Caldwell Luc incision extended medially till midline
Le Fort 1 osteotomy
Infratemporal fossa approach
Anterior subcranial approach
Surgical approaches
1. Trans-palatal approach (Wilson)
small tumour in nasopharynx
2. Sublabial + Trans-palatal approach (Sardana)
large tumour of nose + PNS + nasopharynx
3. Intranasal endoscopic approach
small tumour in nose / PNS / nasopharynx
Surgical approaches
4. Transmaxillary approach via:
 Extended lateral rhinotomy incision
 Midfacial degloving incision
 Denker’s extended Caldwell-Luc incision
 Le Fort 1 osteotomy approach
Done for extension into pterygopalatine fossa
Surgical approaches
5. Infratemporal fossa approach (Fisch)
extension into infratemporal fossa
6. Anterior subcranial approach
intracranial & orbital extension
7. Image-guided, endoscopic, laser-assisted
removal (latest): small / medium size tumors
Surgical specimen
Surgical specimen
Proton Stereotactic Radiation
Therapy (P.S.R.T.)
Synonym: Gamma knife surgery
Used for: 1. Intracranial extension
2. Recurrence after surgery
• Single relatively high dose of radiation delivered
precisely to a small area to kill tumor cells
• Minimal injury to adjacent nerves & brain tissue
Stereotactic Radiotherapy
Thank You