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Nasopharyngeal Angiofibroma

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,

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Nasopharyngeal Angiofibroma

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  1. Nasopharyngeal Angiofibroma Dr. Vishal Sharma

  2. 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

  3. Site of origin Arises in posterior nasal cavity, near superior border of sphenopalatine foramen

  4. Sphenopalatine foramen

  5. 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).

  6. Histopathology

  7. Small tumour

  8. Nasal cavity

  9. Nasal cavity & P.N.S.

  10. Nasopharynx

  11. Pterygopalatine fossa

  12. Infratemporal fossa

  13. Infratemporal fossa

  14. Cheek

  15. Orbit

  16. Sphenoid sinus

  17. Middle cranial fossa

  18. Pituitary & Cavernous sinus

  19. Spread Anterior:Nasal cavity + paranasal sinus Posterior:Nasopharynx Lateral:goes to Pterygopalatine fossa 1. Infratemporal fossa  cheek 2. Inferior orbital fissure  orbit

  20. Spread Superior:1. Sphenoid sinus  Middle cranial fossa  Cavernous sinus  Optic chiasma  Pituitary fossa 2. Skull base  Middle cranial fossa

  21. 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

  22. Facial swelling

  23. 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

  24. 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

  25. Other Investigations  M.R.I.:for intra-cranial involvement  Digital Subtraction Angiography (D.S.A.):a. extent of tumor b. tumour blush (due to increasedvascularity)c. feeding arteries for embolization  Biopsy: contraindicated (profuse bleeding)

  26. Magnetic Resonance Imaging

  27. D.S.A. before embolization

  28. D.S.A. after embolization

  29. Differential diagnosis • Rhabdomyosarcoma • Antrochoanal polyp • Teratoma • Dermoid • Encephalocoele • Inverting papilloma • Squamous cell carcinoma

  30. Staging Stage I: Tumor limited to nasal cavity or nasopharynx with no bony destruction Stage II:Tumor invading pterygopalatine fossa or paranasal sinusesStage III: Tumor invading infratemporal fossa or orbit or parasellar region Stage IV:Tumor invading cavernous sinus or optic chiasma or pituitary fossa

  31. 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

  32. Trans-palatal approach

  33. Trans-palatal approach

  34. Trans-palatal approach

  35. Sardana’s approach

  36. Endoscopic approach

  37. Lateral rhinotomy approach

  38. Lateral rhinotomy approach

  39. Midfacial degloving

  40. Denker’s incision Caldwell Luc incision extended medially till midline

  41. Le Fort 1 osteotomy

  42. Infratemporal fossa approach

  43. Anterior subcranial approach

  44. 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

  45. 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

  46. 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

  47. Surgical specimen

  48. Surgical specimen

  49. 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 tumorcells • Minimal injury to adjacent nerves & brain tissue

  50. Stereotactic Radiotherapy

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