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Juvenile Nasopharyngeal Angiofibroma: Evaluation and Treatment

December 2012

TITLE: Juvenile Nasopharyngeal Angiofibroma: Evaluation and Treatment


SOURCE: Grand Rounds Presentation, Department of Otolaryngology
The University of Texas Medical Branch (UTMB Health)
DATE: December 19, 2012
RESIDENT PHYSICIAN: Viet Pham, MD
FACULTY PHYSICIAN: Shraddha Mukerji , MD
SERIES EDITOR: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Quinn, MSICS
"This material was prepared by resident physicians in partial fulfillment of educational requirements established for
the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was
not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a
conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty
and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."

INTRODUCTION
A rare tumor that comprises only 0.5% of neoplasms in the head and neck (Herman 1999,
Tewfik 1999), juvenile nasopharyngeal angiofibroma (JNA) is pathognomonically characterized
as a benign vascular tumor located in the posterior nasopharynx of adolescent males. Although
not a malignant process, JNA is known for its locally invasive spread with progressive growth
that can attribute to a significant degree of morbidity commonly related to either intracranial
extension or massive hemorrhage.
JNA was first described in conjunction with nasal polyps by Hippocrates in the 5th
century BC (Babyn 2005), but it was Chelius who distinguished it as one associated with puberty
in 1847. Initially regarded as a fibrous nasal polyp at that time, the term angiofibroma was not
coined until Friedberg did so in 1940 (Gullane 1992).
DEMOGRAPHICS
There is a strong predilection for JNA to affect teenage males, typically between 14-15
years of age, although the reported age range spans between 10-25 years of age (Ardehali 2010).
It exhibits a generally indolent course with symptoms commonly lasting for 6-12 months prior to
diagnosis, with approximately 70% of individuals already demonstrating at least a stage II
clinical presentation upon diagnosis (Radkowski 1996).
ORIGIN
The internal maxillary artery is the most common vascular source from which JNAs
arise. Other known vessels include the ascending pharyngeal artery as well as the external,
internal, and common carotid arteries. While not a frequent occurrence, JNAs have also been
known to develop from blood supply contralateral to the side they form. The exact site that JNA
originates from remains controversial although most accept the assertion that it involves the
posterolateral nasal wall at the sphenopalatine foramen. However, there is a minority that
believes JNA is related more to the vidian canal.

Juvenile Nasopharyngeal Angiofibroma: Evaluation and Treatment

December 2012

Similarly, the pathophysiology to JNA formation remains hotly contested. Given its
typical location near the superior margin of the sphenopalatine foramen, there has been some
postulation that the underlying mechanism derives from the embryologic chondrocartilage of the
skull bones (Schiff 1959), particularly at the trifurcation of the palatine bone, horizontal ala of
the vomer, and the root of the pterygoid process (Neel 1973, Bremer 1986).
Given its essential exclusivity to adolescent males, there has been some belief that JNA
development is related to the pituitary androgen-estrogen axis (Schiff 1959), especially with the
observation of androgen and estrogen receptors noted on some JNA cells (Montag 2006). While
plausible, there has been no endocrinologic abnormality identified among individuals with JNA
(Neel 1973, Sessions 1981, Shikani 1992). Other theories suggest a role for vascular endothelial
growth factor receptor-2, transforming growth factor beta 1, or insulin-like growth factor 2
(Coutinho-Camillo 2008), while other ideas suspect that JNA is more of a vascular hamartoma
(Girgis 1973) or inflammatory reaction.
HISTOLOGY
Histologically, JNA exhibits cells of myofibroblast origin surrounded by a fibrous
pseudocapsule. There are multiple vascular channels dispersed within the neoplasm composed
of abundant endothelial cells embedded in a collagenous tissue network. An important hallmark
is the lack of a true muscular layer, and this absence precludes any form of vasoconstriction and
is felt to contribute to the tumors high propensity for hemorrhage (Liu 2002).
PRESENTATION
The manner JNA conventionally declares itself is with unilateral nasal obstruction or
recurrent epistaxis in an adolescent male. Physical examination will commonly reveal a smooth
and lobulated, compressible purplish or reddish nasal mass. Surrounding structures in the
nasopharynx may result in atypical symptoms including middle ear effusions and conductive
hearing loss with blockage of the Eustachian tubes, rhinolalia, palatal deformity, hyposmia, or
anosmia.
With more advanced tumors, anterior extension may impede the nasolacrimal duct and
result in dacrocystitis. Further progression may manifest with a facial swelling or proptosis
while encroachment toward the intracranial vault will lead to headaches or cranial neuropathies.
Massive hemorrhage is typically affiliated with a large tumor burden.
NATURAL HISTORY
The key element of JNA behavior is submucosal extension toward the pterygomaxillary
fossa, infratemporal fossa, or the superior orbital fissure (Radkowski 1996, Enepekides 2004).
Involvement of the superior orbital fissure facilitates invasion of the cavernous sinus or orbit.
Intracranial extension occurs in 20-36% (Close 1989, Wiatrak 1993), typically with either the
anterior or middle cranial fossae or the pituitary parasellar region. Despite the morbidity
associated with intracranial spread in general, actual dural penetration is rare with JNA and is
one reason some surgeons do not indiscriminately regard all such cases as unresectable.
Complete surgical extrication is vital to definitive treatment of JNA as an incomplete
resection is the leading etiology for recurrence, estimated to occur in up to 46% depending on

Juvenile Nasopharyngeal Angiofibroma: Evaluation and Treatment

December 2012

surgical technique (Fagan 1997). The risk is higher for tumor extension to the sphenoid sinus,
pterygoid base, and the clivus. Interestingly, spontaneous regression has been described in some
cases, particularly in individuals older than 25 years of age leading to speculation that this
phenomenon is related to post-pubertal hormonal changes (Tosun 2008). Others have contested
this with the observation that regression is only possible for residual tumors that had undergone
prior treatment (Neel 1973, Stansbie 1986, Mishra 1989).
DIFFERENTIAL DIAGNOSIS
A myriad of other neoplasms can masquerade with a similar appearance as JNA, which is
an important consideration given its overall rarity. Pyogenic granulomas and
hemangiopericytomas can present in the nasal passages and also be affiliated with a certain
degree of epistaxis. Nasal polyps are other masses more commonly encountered in the nasal
cavity, albeit with a lower propensity for hemorrhage. Other tumors involving the skull base can
emulate a locally advanced JNA such as a craniopharyngioma, chordoma, chondrosarcoma,
nasopharyngeal carcinoma, olfactory neuroblastoma, or rhabdomyosarcoma.
STAGING
The first classification scheme employed to better define JNA was introduced by
Sessions in 1981, and there have been multiple modifications since then including those
described by Fisch (1983), Chandler (1984), and Andrews (1989). The staging system
introduced by Radkowski constitutes the most recent adaptation and focuses more on the
tendency for JNA to extend posteriorly toward the pterygoid plates and also distinguishes the
degree of skull base erosion present (Radkowski 1996). Table 1 presents this scheme below.
Ultimately, however, no classification system has been universally accepted, and it is not
uncommon for various articles to discuss their results using different systems.
Table 1. Radkowski JNA Classification System

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December 2012

RADIOLOGY
JNA exhibits a characteristic appearance on roentgenology that often makes obtaining a
biopsy redundant. Such a diagnostic approach is favorable given the potentially high risk for
significant hemorrhage from such neoplasms. Key features to support a diagnosis of JNA
include the presence of a vascular mass with an epicenter at the posterior nasal cavity near the
medial pterygopalatine fossa, the presence of bony modelingbut not destructionwith tumor
growth, and the lack of regional or distant metastasis (Amdur 2011). For atypical extension or
unexpected rapid growth, a biopsy should be considered to assess for other neoplasms aside from
JNA.
JNA will demonstrate an intense homogenous contrast enhancement on computed
tomography (CT). An important advantage of CT imaging is its superiority in evaluating bony
details compared to magnetic resonance imaging (MRI), and this is best exemplified with an
anterior bowing to the posterior maxillary sinus wall that JNA is commonly associated with
known as the Holman-Miller sign. Widening of the sphenopalatine foramen may also be
observed.
Diffuse intense contrast enhancement is also noted with JNA on both T1- and T2weighted MRI. The utility of MRI is demonstrated with its improved soft tissue differentiation
compared to CT, as it is able to delineate mucosal inflammation versus sinus fluid and assist with
accurate tumor staging. MRI is also crucial in assessing the degree of intracranial extension, and
flow voids within the numerous tumor vessels have been described on MRI scans (John 2006).
ANGIOGRAPHY
JNAs dependence on the carotid arterial system has understandably directed attention to
evaluate the potential benefit of angiography. In addition to identifying the source vessel,
angiography may serve as a vector for embolization prior to surgical excision. Furthermore, a
balloon occlusion test of the carotid may be conducted to facilitate appropriate preoperative
counseling (Danesi 2008). Despite its utility in managing JNA, angiography is not a required
diagnostic endeavor and surgical excision may still be performed in the absence of it (Ahmad
2008).
Preoperative embolization is generally undertaken 24-72 hours prior to resection and
often employs either gelfoam or polyvinyl alcohol foam. Gelfoam generally lasts for
approximately two weeks while polyvinyl alcohol foam is more permanent. The rationale is that
occluding the responsible artery from which the JNA originates will decrease intraoperative
blood loss and even decrease the tumor size to augment resectability. Complications associated
with embolization include the potential for cerebrovascular accident if one of the carotids is
affected, blindness if the ophthalmic artery is embolized, and necrosis of skin and soft tissue
depending on which vascular supply has been compromised. Facial paralysis has also been
reported, but this was in conjunction with a preauricular approach for surgical excision and it is
plausible that the facial palsy may be attributed more to the surgical excision as opposed to the
embolization.
A number of studies support the role of embolization in reducing intraoperative blood
loss (Moulin 1995, Li 1998, Liu 2002). However, Moulin reported statistical significance of this

Juvenile Nasopharyngeal Angiofibroma: Evaluation and Treatment

December 2012

occurrence only for larger staged tumors while Liu noted similar findings only for smaller ones
limited to the nasal cavity or nasopharynx. Liu also compared embolization with carotid ligation
and did not appreciate a difference between the two in regards to hemorrhage.
SURGERY
The primary treatment modality is surgical excision (Marshall 2006), and it remains a
viable option in cases of intracranial extension (Bales 2002). While preoperative embolization is
regarded as a beneficial adjuvant therapy, it can obscure tumor borders and complicate resection
(Andrade 2007). Recurrence is highly related to incomplete removal, with most reports
estimating that this occurs in 6-37.5% of surgeries (Fagan 1997, Hosseini 2005, Cansiz 2006,
Hyun 2011) within six months postoperatively (Tyagi 2006). However, the surgical plan needs
to consider that a more extensive resection in an attempt to prevent recurrence is inherently
associated with a higher degree of morbidity. Areas of most concern include the pterygoid fossa,
clivus, basisphenoid, sphenoid diploe, cavernous sinus, and intracranial vault.
A transpalatal approach involves splitting and retracting the soft palate to expose the hard
palate. A portion of the palatine bone and inferior pterygoid plate is then removed to facilitate
access to the nasopharynx from which the JNA can be removed. In general, the transpalatal
approach is ideal for tumors limited to the sphenoid sinus as there tends to be limited lateral
exposure, but Le Fort I osteotomies may permit access to the paranasal sinuses, pterygopalatine
fossa, and infratemporal fossa (Yiotakis 2008). The major risks associated with this approach
include palatal dehiscence and the formation of an oroantral fistula.
Creating a lateral rhinotomy incision provides an external approach to access more of the
nasal cavities and nasopharynx, allowing for resection of larger tumors. A number of variations
of this have been introduced that revolve around making a Weber-Fergusson incision with
various extensions to customize the exposure necessary to remove a JNA. This includes
combinations with a Lynch extension, lateral subciliary extension, and subciliary and
supraciliary extensions. While exposure is greatly enhanced compared to a transpalatal
approach, it comes with the caveat that a potentially unsightly scar may develop.
The midfacial degloving technique attempts to recreate the superior exposure afforded by
a lateral rhinotomy but without the associated external incisions. In general, this involves
creating a gingivobuccal incision coupled with intercartilagneous and transfixion incisions
similar to those made in an external rhinoplasty. This is to essentially translocate the soft tissue
of the midface off the bony midface of the skull, and access into the nasal passages is provided
via Le Fort I osteotomies.
While cosmetically favorable, midfacial degloving is affiliated with a number of potential
sequelae with nasal crusting being the most common. Others include epistaxis, nasal vestibular
stenosis, nasolacrimal duct obstruction, facial paresthesia, and facial nerve palsy. An oroantral
fistula could still arise, and carotid artery rupture is a rare but previously reported complication.
Historically, locally advanced JNAs were addressed with a large, extensive infratemporal
fossa approach with possible craniotomy. As surgical techniques have progressively been
refined, anterior access is now felt to be sufficient for most intracranially invading tumors and
use of a craniotomy is less common. A transfacial, transmaxillary approach is generally utilized

Juvenile Nasopharyngeal Angiofibroma: Evaluation and Treatment

December 2012

for such situations (Elsharkawy 2010), and a medial maxillectomy is often believed to be
required to access the medial infratemporal fossa, cavernous sinus, sphenoid sinus, or anterior
skull base (Fagan 1997). There is growing sentiment that endoscopic access is feasible in select
cases (Danesi 2008), and others have advocated a combined endoscopic and external approach
(Douglas 2006).
Much interest has been invested in endoscopic resection of JNA given its generally
positive results with avoidance of incisions. The general approach involves creating a middle
meatus antrostomy with a middle turbinectomy as needed for exposure. With a large enough
antrostomy, the posterior maxillary sinus wall can then be removed to allow ligation of the
sphenopalatine artery and any other vascular contributions in the area. Tumor resection from the
pterygopalatine fossa can then proceed. Some disadvantages with endoscopic removal include
the difficulty in employing simultaneous instrumentation (Wormald 2003), limited tumor
mobilization inside the nasal cavity (Douglas 2006), and significantly impaired visualization
with brisk hemorrhage (Yiotakis 2008).
One of the more common complications related to endoscopic tumor resection includes
nasal synechia. Given the various neurovascular structures nearby, other possibilities include
lacrimal duct stenosis, cheek paresthesia with damage to the maxillary nerve, and vision changes
if cranial nerves III or IV are impacted. Sphenoid mucocele formation has been reported in
addition to few accounts of cavernous sinus injury.
Acknowledging variations among institutions, stage I and II tumors have been felt to be
best addressed with either transpalatal or endoscopic methods while a lateral rhinotomy or
midfacial degloving was reserved for stage III tumors (Hosseini 2005). Others have generally
followed suit, but there has been a shift favoring endoscopic removal of JNA (Mann 2004). The
endoscopic approach was observed to manifest with less intraoperative blood loss, a shorter
operative time, and a brief hospitalization as compared to either the transpalatal and midfacial
degloving techniques for stage I and II tumors (Yiotakis 2008). Endoscopic removal has been
deemed feasible for even stage IIIA tumors (Wormald 2003), and this is further augmented with
decreased intraoperative and postoperative hemorrhage and a shorter hospitalization when
combined with preoperative embolization (Ardehali 2010).
RADIATION
Originally reserved for unresectable or life-threatening tumors, radiotherapy (XRT) is an
alternative treatment modality in managing JNA. Therapeutic results were appreciated with dose
ranges between 30-46Gy (McAfee 2006, Chakraborty 2011), and primary XRT has been
demonstrated to be just as effective as surgery with a 15% recurrence rate (Reddy 2001). The
associated complication rate is low but more notable ones include temporal lobe necrosis (Lee
2002), cataracts (Amdur 2011), arrest of craniofacial growth, induction of future malignancies
(Witt 1983) such as a fibrosacoma (Makek 1989), hypopituitarism, and osteoradionecrosis (Witt
1983).
XRT has historically been regarded to attain tumor control rates between 80-85% (Briant
1978, Cummings 1984, Reddy 2001), although Amdur reported control rates up to 90% and
concluded that neoadjuvant XRT prior to a planned subtotal resection and adjuvant XRT for
microscopically positive surgical margins were of minimal benefit. Furthermore, elective nodal

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December 2012

irradiation was deemed unnecessary, and most recurrences after XRT would manifest by two
years after treatment. The diagnosis of JNA should be questioned if there was a size decrease of
less than 50% by one year post-treatment, and while there was no evidence to support the notion,
there was concern that tumor hypoxia from preoperative embolization might impart
radioresistance (Amdur 2011).
MEDICAL AND OTHER THERAPY
Chemotherapy has been investigated as treatment options in cases of JNA that had
recurred after surgery and XRT, but a low therapeutic benefit coupled with poorly tolerated side
effects has made this a rarely used endeavor (Lee 2002).
Given its sole demographic of adolescent males, hormonal therapy was hypothesized to
decrease the size and vascularity to JNAs via estrogens or antiandrogens. The theory was that
the reduced vascularity would support decreased intraoperative blood loss during surgical
resection, and it was hoped that the antiandrogenic push would promote tumor regression.
However, the physical and psychological side effects from such medications are understandably
poorly tolerated in such young patients and serve as a significant impediment to their use,
especially given the lack of efficacy with flutamide (Labra 2004).
Other treatment modalities that have been reportedly implemented to address JNA
include coblation (Ruiz 2012), cryotherapy (Witt 1983, Spector 1988), electrocoagulation (Schiff
1959), gamma knife (Dare 2003, Park 2006), harmonic scalpel (Chen 2006), interstitial
brachytherapy (Reddy 2001), KTP-laser embolization (Hazarika 2002), and sclerotherapy (Schiff
1959). However, further studies are warranted to further elucidate their role in the mainstay
treatment of JNAs.
CONCLUSION
JNA is a rare vascular neoplasm localized to the posterolateral nasopharynx of adolescent
males that typically presents with either nasal obstruction or recurrent epistaxis. Surgery and
XRT constitute the primary treatment options, but given the rarity by which JNA occurs, it is
important to evaluate for other neoplasms that may also manifest in the nasal cavity.
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