Anterior approaches in juvenile nasopharyngeal angiofibromas with intracranial extension

Although surgery is regarded as the mainstay of treatment for juvenile naso pharyngeal angiofibromas (JNAs), ancillary treatment modalities such as rad iotherapy and on rare occasions chemotherapy are still recommended by many for intracranial extension with apparent radiologic involvement of the cave rnous sinus and internal carotid artery. Further, most authors undertaking surgical excision of this subgroup of patients would recommend a lateral or combined frontal and lateral approach for its removal, In a series of 49 c ases of JNA, 14 were found during surgery to have intracranial extradural e xtension; the anterior approach was used for their removal. Although in the se cases, on radiography the cavernous sinus often looked to be invaded and the internal carotid artery was displaced superolaterally, there was no di fficulty in establishing a plane of dissection. Total removal was achieved in 11 of the 14 cases with a single-stage procedure. Of the 3 cases with re sidual tumor, only 1 occurred intracranially. Removal was achieved by a sub temporal approach in this case. For the extracranial residual tumors 1 requ ired a midface degloving and the other, with a l-cm residual tumor in the n asopharynx, has been treated conservatively for 6 years with no evidence of growth. No deaths or significant complications have occurred, and radiothe rapy has not been required. We conclude that JNAs are tumors with a predile ction for spread but that rarely invade dura, acting instead to displace it . We believe that surgery is the method of choice for treating these lesion s and that an anterior surgical approach with microsurgical techniques shou ld be used in the first instance. In the last 2 cases we preferred a midfac e degloving technique to avoid facial scarring and because this approach al lows a widening of the surgical field if needed by the performance of bilat eral maxillary free bone flaps. On the rare occasion that a lateral approac h, with its attendant permanent conductive hearing loss, is found to be nec essary for total tumor removal, this can be done as a staged procedure. Thi s may be necessary when the tumor has spread lateral to the horizontal inte rnal carotid artery.