What is the Fisch staging system for juvenile angiofibromas?

Fisch Staging System for Juvenile Nasopharyngeal Angiofibroma

The Fisch staging system classifies juvenile angiofibromas based on tumor extent and anatomical involvement, guiding surgical approach selection and predicting operative complexity.

Fisch Classification Stages

The Fisch staging system divides juvenile angiofibromas into four main stages based on tumor extension:

Stage I

• Tumor limited to the nasopharynx and nasal cavity 1, 2
• No bone destruction 1
• Amenable to endoscopic transnasal approach 1, 3

Stage II

• Tumor invades the pterygopalatine fossa or maxillary, ethmoid, or sphenoid sinuses with bone destruction 1, 2
• Stage II lesions can be managed endoscopically or via modified midfacial degloving approach 3

Stage III

• Tumor extends into the infratemporal fossa, orbit, or parasellar region, remaining lateral to the cavernous sinus 1, 2
• Stage III is subdivided into:
  • Stage IIIa: Infratemporal fossa involvement 1
  • Stage IIIb: Infratemporal fossa with orbital extension 1
• Requires open surgical approaches, typically modified midfacial degloving 3

Stage IV

• Tumor extends into the cavernous sinus, optic chiasm, or pituitary fossa 1, 2
• Stage IV is subdivided into:
  • Stage IVa: Cavernous sinus involvement (intracranial, extradural) 1
  • Stage IVb: Cavernous sinus with intradural involvement (not commonly reported in the evidence)
• Requires combined approaches including infratemporal fossa dissection with or without craniotomy 3

Clinical Application

The Fisch staging system directly determines surgical approach selection:

• Stages I-II: Endoscopic transnasal resection is feasible and preferred 1, 3
• Stage III: Modified midfacial degloving or conservative external approaches provide adequate exposure 1, 3
• Stage IV: Combined approaches (midfacial degloving plus infratemporal fossa Fisch C approach ± transcranial access) are necessary 3

Critical Considerations

Preoperative embolization should be performed 24-72 hours before surgery for all surgical candidates to minimize intraoperative hemorrhage 4, 1, 2

Never biopsy a suspected juvenile angiofibroma—diagnosis is made clinically by identifying a vascular posterior nasal or nasopharyngeal mass in an adolescent or preadolescent male 5, 4

The Fisch system remains one of the two most commonly used staging systems alongside the Radkowski classification, with the Fisch system being particularly useful for planning surgical corridors in advanced disease 6.