MANAGEMENT OF JUVENILE

NASOPHARYNGEAL
ANGIOFIBROMA WITH MIDFACIAL
DEGLOVING APPROACH: A CASE
REPORT
Nikita Frinadya, Ashri Yudhistira
Introduction
 INTRODUCTION

Recurrence has
been reported to be
Surgical resection is 20 – 42%
the first line treatment
in many centres

JNA is a locally
aggressive benign
vascular tumour
Exclusively amongst
adolescence male.
Age distribution between
14 – 25 years

Juvenile
Nasopharyngeal
Angiofibroma
INTRODUCTION

JNA accounts for only 0.05% of all head and neck tumours. The insidence of
JNA is approximately between 1:5.000 -1:60.000

The tumor origin can be found on the posterolateral wall of the nasopharynx at
the upper edge of the sphenopalatine foramen

An adolescent male with recurrent epistaxis and chronic nasal obstruction is

highly suspicious for a JNA. Other common symptoms include headache,
facial swelling, unilateral rhinorrhoea, hyposmia, and ipsilateral conductive
hearing loss

Diagnosis is based on history, clinical examination and radiological and

imaging results, knowing that biopsy is not recommended
CASE REPORT
 A 14-year-old boy came to ENT clinic Haji Adam Malik Medan general
hospital (Oktober 1st, 2018) with history of nasal obstruction

• Nasal obstruction
• Recurrent nose bleeding
• Loss of smell
• Voice change

Case
Report
 Nasoendoscopy

• Redish-white
mass with smooth
surface covering
the choana

Case
Report
 CT SCAN

• Mass within the

nasopharynx
spreading to
choana, right and
left nasal cavities,
left ethmoid dan
sphenoid
Case sinusitis, and

Report urging of hard

palate
 Angiography

• Angiography was
performed with
embolization
• Vascular mass
fed dominantly by

Case the left maxillary

artery
Report
• The surgical excision of tumor took place on 6th November, 2018
under general anesthesia by midfacial degloving approach
• Patient was lied down on surgical table with IV line and ETT
attached
• surgical area was disinfected with povidone iodine and alcohol
70%
• infiltration was carried out with pehacain 2% + sodium chloride
0.9% (2 : 3) from left-right sublabial area to left-right maxillary
tuberosities.
• Incision was performed on sublabial mucosa from maxillary
tuberosity to periosteum
• septal incision was performed from anterior nasal spine to
nasofrontal suture
• Two catheters were inserted to both nostrils
• Tumor mass was found filling the nasopharynx
• elevatorium was inserted through piriformis aperture and
tumor was released from where it attached, assisted by
fingers inserted through the mouth.
• Once separated, tumor mass was extracted out and the
size of the mass was approximately 10 x 7 x 5 cm
DISCUSSION
 • Juvenile nasopharyngeal angiofibromas (JNAs) are
rare fibrovascular tumors that account for less than
0,5% of all head and neck tumors. The incidence of
Persky & Manolidis, 2014
JNA is approximately 1: 150.000, and it affects
adolescent boys and men between the ages of 14
and 25 years.

In this case, the patient was a 14-year-old male.

 • The two cardinal symptoms of angiofibroma are
nasal obstruction and intermittent unprovoked
epistaxis. The nasal obstruction is so complete
Gupta et al, 2015 causing stasis of secretions and sepsis become
inevitable. Patients may even have hyposmia or
anosmia. The voice of the patient acquires a nasal
intonation.

In this case, the patient presented with intermittent epistaxis, nasal obstruction, hyposmia
and a nasal intonation in his voice.
 • The diagnosis of a JNA is usually made by nasal
Persky & Manolidis, 2014 endoscopy based on suspected presenting
symptomatology.

In this case, the clinical manifestation of the tumor was characteristic of JNA.
Nasoendoscopy showed nasopharyngeal mass spreading to both nasal cavities and
urging his soft palate and the pattern suggestive for JNA .
 • CT is a most important pre-operative test because it
is useful for showing the destruction of bony
Thakar et al., 2013
structures and widening of foramen and fissures at
the skull base due to spread of tumor

In this case, contrast enhanced CT is an intensely stained lesion growing in the

nasopharynx and both nasal cavity urging the soft palate.
 • Angiography and embolization should be performed in patients
when surgery is contemplated. The vascular anatomy of JNA is
Perky & Manolidis, 2014
important in the planning of surgical resection. Blood supply is
determined by the size and extension of the tumor.

• Pre-operative embolisation is now becoming routine practice and is

undertaken with gelfoam or PVA particles 1-2 days prior to surgery.
Thakar et al., 2013 Embolisation decreases intra operative blood loss and improves the
surgical field, and thereby aids in achieving complete tumour
excision

In this case, angiography was performed with embolization. The vascular mass of the
nasopharynx is fed dominantly by the left maxillary artery.
 • Various methods have been used to treat patients with nasopharyngeal
Twu et al., 2002 angiofibroma, including cryotherapy, sclerosing therapy, hormonal
treatment, irradiation therapy, chemotherapy, embolization and surgery

Tan & Loh, 2010 • The primary treatment is surgical extirpation.

• While cosmetically favorable, midfacial degloving is affiliated with a

Thakar, et al., 2013 number of potential sequelae with nasal crusting being the most
common.

In this case we performed an operation by midfacial degloving. This procedure provided a

good exposure of the lesion and will not cause any cosmetical problems afterwards.
CONCLUSION
We report a case of a 14-year-old boy, who presented with nasal
obstruction, recurrent epistaxis, hyposmia and a nasal intonation
in his voice. The clinical manifestation of the tumor was
characteristic of JNA. Preoperative Angiography and
embolization was performed for identification of the feeding
vessels, and we choose to perform an operation by midfacial
degloving approach
Thank you