157 Endoscopic Endonasal and Transmaxillary Resection of Juvenile Nasopharyngeal Angiofibroma: A Modern Treatment Paradigm

INTRODUCTION: Advanced juvenile nasopharyngeal angiofibroma (JNA) has historically been resected via open transfacial and transcranial approaches. Recently, endoscopic endonasal/transmaxillary surgery (EETS) has emerged as a safe and effective alternative. METHODS: Retrospective review of patients treated with EETS for JNA between 2009-2022. RESULTS: Thirty-seven patients were included. All were male with a median age of 14.2 years (range 7.5-17.8). Twenty-one (57%) were UPMC stage V (intracranial extension with residual post-embolization vascularity). Median tumor volume was 42 cm 3 (range 1.3-209). Despite many tumors with significant extension to the intracranial compartment (n=21,57%), infratemporal fossa (n=24.65%), cavernous sinus (n=19.51%), and orbit (n=16.43%), all were successfully resected primarily with EETS. The anterior transmaxillary corridor was used for lateral extension (n=19.51%). Two cases (6%) required lateral orbitotomy and one subtemporal craniotomy (3%) for complete resection of medial sphenoid wing tumor. The rate of gross total resection was 86% (n=30). Preoperative embolization was performed routinely (n=35.95%), but advanced stage tumors (n=26.70%) suffered significant blood loss (median 1.9 L, range 750 ml-16L). Six patients (16%) required staged resection due to blood loss. Most tumors (n=28.80%) had residual vascular supply from the internal carotid (ICA) (n=23) and ophthalmic arteries (n=3). Postoperative complications included an embolization-related stroke (n=1.3%), complete monocular blindness due to central retinal artery occlusion (n=1.3%), and ICA injury requiring vessel sacrifice (n=1.3%) without consequence. Eight patients (22%) suffered recurrence at a median of 8.5 months postoperatively (range 5-33). Five recurrences were completely resected via EETS, but three in the medial sphenoid wing (38%) required addition of lateral orbitotomy. CONCLUSIONS: EETS is safe and effective for resection of all JNAs in children. It offers excellent exposure even in large tumors with lateral or intracranial extension. In rare cases of disease with sphenoid wing extension, addition of lateral orbitotomy can facilitate complete resection.