Nasopharyngeal Angiofibroma is a benign tumor of the nasopharynx composed of fibrous connective tissue and an abundance of endothelium lined vascular ...
In conclusion, Fibreoptic bronchoscopy provided overall diagnostic yield in 92.30% cases and diagnostic yield for tuberculosis in 69.22% cases. It aids in early diagnosis by m i c r o s c o p i c and h i s t o p a t h o l o g i c a l e x a m i n a t i o n o f bronchoscopic specimens, which in turn helps in prompt commencement o f anti-tuberculous treatment that arrests the progression o f disease and limits its spread in the community. ACKNOWLEDGEMENTS The authors wish to express their gratitude to Department of Tuberculosis, Medicine, Microbiology and Miss Anushri Mundada for their valuable help. Our thanks are due to Dr. A.C. Mohanty Dean, IGMC. Nagpur for permitting us to publish this work. REFERENCES 1. Khoo K.K.; Meadway J. (1989): Fibreoptic bronchoscopy in rapid diagnosisof sputum smear-negativepulmonarytuberculosis. Respiratory Medicine; July; 83(4): 335-8.
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Kohno S. (1990): Diagnostic value of bronchoscopy in the diagnosis of pulmonary tuberculosis; bronchial washing and transbronchall lung biopsy. Kekkau ;Jan, 65 (1): 33-36
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MehtaJ.; Krish G.; Berro E. et al (1990): Fibreoptic bronchoscopy in the diagnosis of pulmonarytuberculosis. South Medical Journal, July; 83 (7): 753-5.
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Wongthim S.; Udompanich V. et al (1989): Fibreoptic bronchoscopy in diagnosis of patients with suspected active pulmonary tuberculosis. Journal of Medical Association of Thailand, March; 72 (3): 154-9
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NASOPHARYNGEAL ANGIOFIBROMA (A REPORT OF 19 CASES) R.S Tiwari 1, A.A. Desai 2, R. G. Aiyer 3, V.K Pandya 4 Sandeep BansaP, Ajoy Mathew Varghese 6
INTRODUCTION Nasopharyngeal Angiofibroma is a benign tumor of the nasopharynx composed of fibrous connective tissue and an abundance of endothelium lined vascular spaces. It is a disease afflicting mainly adolescent males. The lesion is b e n i g n but c h a r a c t e r i z e d by local a g g r e s s i o n . In advanced cases the tumor may extend intracranially. The
first recorded description of this tumor was given by Chelins (1847) and the term ~'angiofibroma" given by Friedberg (1940). Recurrent epistaxis with nasal obstruction in a young male should raise the suspicion of angiofibroma. The management of these tumors has been a subject o f much interest and controversy in the past.
IProf & Head Of Department Of ENT, Government Medical College, Bhavnagar, 2Prof & Head Of Department of ENT, Baroda Medical College & S.S.G Hospital, Vadodara, 3Associate Professor, 4Assitant Professor, SSenior Resident, 6 Resident, Department Of ENT & Head And Neck Surgery, Government Medical College and Sir Sayaji General Hospital, Vadodara, Gujarat.
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Nasopharyngeal Angiofibroma
MATERIALS AND M E T H O D S This study reports the recent experiences at the ENT & Head and Neck Surgery Department of S.S.G. Hospital in the m a n a g e m e n t of 19 cases o f n a s o p h a r y n g e a l angiofibroma from Jan 1995 to Feb 2000. As clinical examination, history and age of presentation pointed towards a diagnosis of nasopharyngeal angiofibroma, all the patients were subjected to CT Scan to confirm the diagnosis and demonstrate the extent of the tumor. The CT findings of angiofibroma are characteristic showing a vascular blush on contrast study (Fig I). This is the mainstay for diagnosis of the tumor as biopsy is contraindicated. All e x c e p t two patients, who had extensive intracranial extension, seen on CT scan, were subjected to the surgical line of treatment.
RESULTS All the patients were male, between the ages of 7 years to 22 years, the mean being 15.4 years. The major symptoms in every case were of nasal obstruction and recurrent epistaxis, the mean duration of symptoms being 15 months. On subjecting the patients to CT Scan, intracranial e x t e n s i o n o f the t u m o r was seen in two patients. Considering, sphenopalatine foramen as the site of origin of Nasopharyngeal angiofibroma, all the 17 tumors were e x c i s e d t h r o u g h the t r a n s m a x i l l a r y a p p r o a c h (i.e. anterolateral, posterolateral and medial walls of maxilla were removed according to the extent of tumor) via either by extended lateral rhinotomy incision (12 cases) o r / b y modified Weber Fergusson incision (5 cases). Complete excision of the tumor was possible in all cases through this apporach. Surgical findings correlated with those of CT Scan. Majority of patients in this study had involvement of one or more paranasal sinuses and pterygomaxillary fossa. Involvement of infratemporal fossa was seen in 5 patients. The internal maxillary artery was identified and ligated in all patients in whom maxillary sinus itself, was not involved b y the tumor (14 Cases). Although the external carotid artery was secured in 3 of the patients having maxillary sinus involvement, it was not ligated or occluded in any of the patients. The blood loss during the surgery ranged from 500 to 1300 ml, the mean being 850-900 ml. Most patients required 2 to 3 units of blood transfusion.
All the excised specimens were sent for histopathological e x a m i n a t i o n which c o n f i r m e d the d i a g n o s i s o f n a s o p h a r y n g e a l a n g i o f i b r o m a in all the cases (Fig II). The post operative period was usually uneventful. Most of the patients were discharged within 1-2 weeks with an advise for regular followup. One patient had developed synechiae on foilowup which were released, and two patients required intranasal polypectomy. No recurrence has been noted till date though 3 patients have been lost to follow up. Cosmetically, the results o f the surgery have been good. (Fig. III) Two of the patients in our series having intracranial extension were advised to go to a centre with all facilities, but they could not afford so. They were put on hormonal therapy (Stilbesterol 5 mg tds) with a plan of starting radiotherapy. As both were lost to followup, the results of hormonal or radiotherapy could not be evaluated. DISCUSSION Nasopharyngeal angiofibroma is a relatively rare neoplasm of head and neck (Incidence 0.5%) but constitutes the most common benign tumor of the nasopharynx. A much higher presentation of this lesion was seen in our series, probably because our hospital is the major referral centre for the adjoining 3 states. The two cardinal symptoms of angiofibroma are nasal obstruction and i n t e r m i t t e n t epistaxis. Expansion and extension of the lesion may lead to facial deformity, lateral swelling of cheek, proptosis producing "frog face" appearance, trismus, headache, diminished vision (due to tenting of optic N), soft palate bulging, nasal intonation, nasal mass, deafness, otalgia, etc. A number of theories have been put forward to explain the origin of angiofibroma by various authors. Nowadays, the sphenopalatine foramen is considered to be the site of origin of angiofibroma. This hypothesis can explain the subsequent behaviour of angiofibroma. It is observed that large tumors present as b i l o b e d dumbell s w e l l i n g with o n e part filling the nasopharynx, the other extending into the infratemporal and pterygopalatine fossae and the central stalk joining the two occupies the sphenopalatine foramen without significant erosion or enlargement of the foramen. Various surgical approaches h a v e been described for
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 52 No. 4, October - December 2000
Nasopharyngeal Angiofibroma
Fig. I :
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Photograph showing characteristic vascular blush seen on CT scan of a patient with nasopharyngeal angiofibroma. Fig. l l l : Clinical photograph showing 2-weeks post operative scar of a extended lateral rhinotorny incision.
Fig. tI :
Micro photograph showing histopathological picture of nasopharyngeal angiofibroma(Mag. 12.5 x 10), H & E.
removal of this tumor including transpalatal, transmandibular, trans antral and the sublabial midfacial degloving approach. With the understanding of the point of origin of the tumor, we believe that transmaxillary approach through the lateral rhinotomy or Weber Fergusson incisions (which can be modified according to the extent of the tumor) is the most direct route to the body of the tumor and is versatile'enough to reach all extracranial extensions of the tumor. This approach also allows the ligation of the internal maxillary artery which negates the need for preoperative angiography _and embo!ization in patients whom the maxillary sinus itself is not involved by the tumor. There are quite a few reports of tumor being treated by radiation therapy with varied results. Many authors advise radiotherapy to be reserved for patients with inoperable intracranial extensions and recurrent tumors. Considering the potential dangers of radiotherapy ranging from a definite risk of thyroid carcinoma, radiation induced sarcoma to osteomyelitis, affliction of growth centres and a potential damage to surrounding structures, the primary treatment should be surgery.
CONCLUSION All the patients in our series were males in the age group of 7-22 years, presenting with recurrent epistaxis and nasal obstruction raising a clinical suspicion of nasopharyngeal angiofibroma. CT Scan played an important role in the diagnosis and knowing the extent of lesion for proper planning of the surgery. The transmaxillary approach via lateral rhinotomy or WF incision results in adequate exposure for complete exeresis of tumor with minimal blood loss, no recurrence and excellent cosmetic results. This approach gives a direct route for the ligation of the internal maxillary artery which negates the need for preoperative angiography and embolization in whom the maxillary sinus is not involved by the tumor. If further experience with this approach to management of this lesion has the same results in a larger series, surgery should be the gold standard in treatment of Nasopharyngeal angiofibroma. REFERENCES 1.
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Address for correspondence DR. R. G. AIYER 3/2, Jesal Apartments Abhishek Colony, Race Cource, Varodara- 390 007
Indian Journal o f Otolarvngology and Head and Neck Surgery Vol. 52 No. 4, October - December 2000
