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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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Slide 1

Nasopharyngeal Angiofibroma

Dr. Vishal Sharma

Slide 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

Slide 3

Site of origin

Arises in posterior nasal cavity, near superior

border of sphenopalatine foramen

Slide 4

Sphenopalatine foramen

Slide 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).

Slide 6

Histopathology

Slide 7

Small tumour

Slide 8

Nasal cavity

Slide 9

Nasal cavity & P.N.S.

Slide 10

Nasopharynx

Slide 11

Pterygopalatine fossa

Slide 12

Infratemporal fossa

Slide 13

Infratemporal fossa

Slide 14

Cheek

Slide 15

Orbit

Slide 16

Sphenoid sinus

Slide 17

Middle cranial fossa

Slide 18

Pituitary & Cavernous sinus

Slide 19

Spread

Anterior:Nasal cavity + paranasal sinus

Posterior:Nasopharynx

Lateral:goes to Pterygopalatine fossa

1. Infratemporal fossa  cheek

2. Inferior orbital fissure  orbit

Slide 20

Spread

Superior:1. Sphenoid sinus

 Middle cranial fossa

 Cavernous sinus

 Optic chiasma

 Pituitary fossa

2. Skull base

 Middle cranial fossa

Slide 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

Slide 22

Facial swelling

Slide 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

Slide 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

Slide 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)

Slide 26

Magnetic Resonance Imaging

Slide 27

D.S.A. before embolization

Slide 28

D.S.A. after embolization

Slide 29

Differential diagnosis

  • Rhabdomyosarcoma

  • Antrochoanal polyp

  • Teratoma

  • Dermoid

  • Encephalocoele

  • Inverting papilloma

  • Squamous cell carcinoma

Slide 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

Slide 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

Slide 32

Trans-palatal approach

Slide 33

Trans-palatal approach

Slide 34

Trans-palatal approach

Slide 35

Sardana’s approach

Slide 36

Endoscopic approach

Slide 37

Lateral rhinotomy approach

Slide 38

Lateral rhinotomy approach

Slide 39

Midfacial degloving

Slide 40

Denker’s incision

Caldwell Luc incision extended medially till midline

Slide 41

Le Fort 1 osteotomy

Slide 42

Infratemporal fossa approach

Slide 43

Anterior subcranial approach

Slide 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

Slide 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

Slide 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

Slide 47

Surgical specimen

Slide 48

Surgical specimen

Slide 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

Slide 50

Stereotactic Radiotherapy

Slide 51

Thank You


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