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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,

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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,

    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 increasedvascularity)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 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

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 tumorcells

  • Minimal injury to adjacent nerves & brain tissue


Stereotactic Radiotherapy


Thank You


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