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Nasopharyngeal Angiofibroma






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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,
Nasopharyngeal Angiofibroma

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Nasopharyngeal angiofibroma l.jpgSlide 1

Nasopharyngeal Angiofibroma

Dr. Vishal Sharma

Definition l.jpgSlide 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

Site of origin l.jpgSlide 3

Site of origin

Arises in posterior nasal cavity, near superior

border of sphenopalatine foramen

Sphenopalatine foramen l.jpgSlide 4

Sphenopalatine foramen

Pathology l.jpgSlide 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).

Histopathology l.jpgSlide 6

Histopathology

Small tumour l.jpgSlide 7

Small tumour

Nasal cavity l.jpgSlide 8

Nasal cavity

Nasal cavity p n s l.jpgSlide 9

Nasal cavity & P.N.S.

Nasopharynx l.jpgSlide 10

Nasopharynx

Pterygopalatine fossa l.jpgSlide 11

Pterygopalatine fossa

Infratemporal fossa l.jpgSlide 12

Infratemporal fossa

Infratemporal fossa13 l.jpgSlide 13

Infratemporal fossa

Cheek l.jpgSlide 14

Cheek

Orbit l.jpgSlide 15

Orbit

Sphenoid sinus l.jpgSlide 16

Sphenoid sinus

Middle cranial fossa l.jpgSlide 17

Middle cranial fossa

Pituitary cavernous sinus l.jpgSlide 18

Pituitary & Cavernous sinus

Spread l.jpgSlide 19

Spread

Anterior:Nasal cavity + paranasal sinus

Posterior:Nasopharynx

Lateral:goes to Pterygopalatine fossa

1. Infratemporal fossa  cheek

2. Inferior orbital fissure  orbit

Spread20 l.jpgSlide 20

Spread

Superior:1. Sphenoid sinus

 Middle cranial fossa

 Cavernous sinus

 Optic chiasma

 Pituitary fossa

2. Skull base

 Middle cranial fossa

Symptoms l.jpgSlide 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

Facial swelling l.jpgSlide 22

Facial swelling

Signs l.jpgSlide 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

C t scan p n s with contrast l.jpgSlide 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

Other investigations l.jpgSlide 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)

Magnetic resonance imaging l.jpgSlide 26

Magnetic Resonance Imaging

D s a before embolization l.jpgSlide 27

D.S.A. before embolization

D s a after embolization l.jpgSlide 28

D.S.A. after embolization

Differential diagnosis l.jpgSlide 29

Differential diagnosis

  • Rhabdomyosarcoma

  • Antrochoanal polyp

  • Teratoma

  • Dermoid

  • Encephalocoele

  • Inverting papilloma

  • Squamous cell carcinoma

Staging l.jpgSlide 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

Pre op reduction of tumor vascularity l.jpgSlide 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

Trans palatal approach l.jpgSlide 32

Trans-palatal approach

Trans palatal approach33 l.jpgSlide 33

Trans-palatal approach

Trans palatal approach34 l.jpgSlide 34

Trans-palatal approach

Sardana s approach l.jpgSlide 35

Sardana’s approach

Endoscopic approach l.jpgSlide 36

Endoscopic approach

Lateral rhinotomy approach l.jpgSlide 37

Lateral rhinotomy approach

Lateral rhinotomy approach38 l.jpgSlide 38

Lateral rhinotomy approach

Midfacial degloving l.jpgSlide 39

Midfacial degloving

Denker s incision l.jpgSlide 40

Denker’s incision

Caldwell Luc incision extended medially till midline

Le fort 1 osteotomy l.jpgSlide 41

Le Fort 1 osteotomy

Infratemporal fossa approach l.jpgSlide 42

Infratemporal fossa approach

Anterior subcranial approach l.jpgSlide 43

Anterior subcranial approach

Surgical approaches l.jpgSlide 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

Surgical approaches45 l.jpgSlide 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

Surgical approaches46 l.jpgSlide 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

Surgical specimen l.jpgSlide 47

Surgical specimen

Surgical specimen48 l.jpgSlide 48

Surgical specimen

Proton stereotactic radiation therapy p s r t l.jpgSlide 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

Stereotactic radiotherapy l.jpgSlide 50

Stereotactic Radiotherapy

Thank you l.jpgSlide 51

Thank You


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