Angiofibromas originate from the sphenopalatine foramen at the junction of the sphenoid process of the palatine bone and the pterygoid process of the sphenoid. Whether endoscopic excision of an angiofibroma is possible depends on its size, on knowledge of its blood supply, and on whether it can be embolized safely (Fig. 15.43 a-e). It is not possible to excise them endoscopically without preoperative embolization. Total removal depends on accessibility and control of their blood supply. The conventional approaches are via a lateral rhinotomy and medial maxillectomy, mid-facial degloving (Price et al., 1988) or transpalatally (Sessions et al., 1993). Larger lesions require the addition of a lateral infratemporal approach.

Angiofibromas at stage Ia, IIa or IIb according to Fisch may be suitable for endoscopic excision (Ene-

pekides, 2004). These lesions comprise only a fifth of all angiofibromas (Newlands et al., 1999). It is important that any surgeon embarking on an endoscopic resection should be able to convert to an open approach as bleeding can necessitate this. It is also important to have blood saved and at least six units of blood cross-matched and to have access to fresh frozen plasma.

Endoscopic resection consists of a type III maxillary sinusotomy, an ethmoidectomy, and removal of the posterior wall of the maxillary sinus in order to define and clip the terminal branches of the maxillary artery and its sphenopalatine branches. The sphenoid is opened if access is possible and then the lesion is removed. The aim is to remove the whole lesion in one piece, but it is often removed in several pieces. It is often necessary to pack and apply pressure to the area b a d c

Resection TurbinatesScans Turbinates

Fig. 15.43 a Endoscopic view of a right angiofibroma. b Preoperative axial CT scan with contrast. c Preoperative MR image and d postoperative axial CT scans. e Endoscopic view at 3 years after resection of angiofibroma.

Clivus Angiofibroma

temporarily in order to reduce bleeding before the next attempt is made to remove any remnant. Large suckers are needed to remove enough blood quickly and allow the lateral wall to be visualized. A suction catheter passed through the other nostril into the nasopharynx also reduces the reservoir of blood in the nasopharynx and helps visibility. The main problem area is removing disease that goes behind and lateral to the pterygoid plates and clivus. The 45° endoscope helps visualize this area, but bleeding often limits this. This is one of the areas where it helps to have one surgeon holding the endoscope while the other has two hands free.

Concern has been expressed that preoperative em-bolization can lead to a higher recurrence rate by reducing bleeding from the tumor, which often has no defined capsule, and this makes it more likely that a remnant will be left behind (McCoombe et al., 1990). It is rarely possible to resect an angiofibroma endoscopi-

cally without pre-embolization, and we recommend that it is done.

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  • monika
    How to remove angiofibroma?
    7 years ago

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