What is the management of angiofibroma?

Management of Angiofibroma

Surgical resection is the standard treatment for angiofibroma, with preoperative embolization recommended to reduce intraoperative bleeding, particularly for juvenile nasopharyngeal angiofibroma (JNA). 1

Types and Presentation

Juvenile Nasopharyngeal Angiofibroma (JNA)

• Rare, benign but locally aggressive vascular tumor
• Occurs predominantly in adolescent males
• Presents with unilateral, unprovoked, and typically profuse epistaxis (60-76% of cases) 1
• Common symptoms include nasal obstruction and rhinorrhea
• Originates in the sphenopalatine fossa, may extend to pterygopalatine fossa, paranasal sinuses, and nasal cavity

Diagnostic Evaluation

1. Nasal Endoscopy: Essential for examination of the nasal cavity and nasopharynx 1

   • Particularly important for adolescent males with unilateral epistaxis
   • Allows visualization of the tumor and assessment of extent

2. Imaging:

   • CT and MRI are complementary for delineating tumor extent
   • MRI shows relationship to brain parenchyma and dural involvement 1
   • Angiography identifies feeding vessels and is performed before embolization 1

Important: Biopsy should NOT be performed for suspected JNA due to risk of significant hemorrhage 1

Treatment Algorithm

1. Preoperative Management

• Preoperative Embolization: Recommended 24-48 hours before surgery 1, 2
  • Reduces intraoperative bleeding
  • Makes endoscopic excision easier and safer
  • Identifies dangerous intracranial anastomoses

2. Surgical Approaches (Based on Tumor Staging)

• Early Stage (Limited Disease):

  • Transnasal endoscopic approach 3, 4
  • Advantages: Less morbidity, better visualization, shorter hospital stay

• Advanced Stage (Extensive Disease):

  • Expanded endonasal approach (EEA) for most cases, even with skull base involvement 3
  • Combined approaches for extensive intracranial extension:
    • Modified midfacial degloving approach 4
    • Combined with infratemporal or transcranial approach for stage IV disease 4

3. Postoperative Management

• Regular follow-up with endoscopic examination
• MRI surveillance to detect recurrence

Special Considerations

Blood Loss Management

• Mean intraoperative blood loss ranges from 500-1900 ml even with embolization 2
• Hypotensive anesthesia techniques help reduce bleeding 5
• Blood transfusion may be required in approximately 30% of cases 2

Recurrence

• Recurrence rates are not necessarily associated with tumor extent or surgical technique 3
• Complete surgical excision is the key to preventing recurrence
• Regular follow-up is essential to detect early recurrence

Potential Complications

• Excessive bleeding
• Synechia formation
• Facial paresthesia (with midfacial degloving approach)
• Temporary facial palsy (with infratemporal approaches)
• Rare but serious: vascular injury

Alternative Approaches

While some studies suggest that preoperative embolization may not be necessary for smaller lesions when using hypotensive anesthesia 5, the consensus from most recent guidelines supports preoperative embolization to reduce surgical risk, especially for larger tumors 1, 2.

Caution: Juvenile nasopharyngeal angiofibroma should not be confused with other vascular tumors like infantile hemangiomas, which have different management approaches 1.