Nasopharyngeal Angiofibroma

NASOPHARYNGEAL ANGIOFIBROMA

• It is a histologically benign but locally aggressive vascular tumor that grows in the back of the nasal cavity.
•  It is the most common benign neoplasm of nasopharynx.
• It is a highly vascular tumor.It consists of fibrous tissue and blood vessels,
• Blood supply of the tumor most commonly arises from the internal maxillary artery. 
• The exact cause is unknown. As the tumour is predominantly seen in adolescent males in the second decade of life, it is thought to be testosterone dependent.
• Such patients have a hamartomatous nidus of vascular tissue in the nasopharynx and this is activated to form angiofibroma when male sex hormone appears.
• Most common site is posterior part of nasal cavity close to the margin of sphenopalatine foramen.
• It may expand into the surrounding areas like nasal cavity,sphenoid sinus,pterygopalatine fossa,maxillary sinus,orbit and cranial cavity.

CLINICAL PRESENTATION OF NASOPHARYNGEAL ANGIOFIBROMA

• Sex : Seen almost exclusively in males (testosterone dependent).
• Age : 10-20 years (2nd decade).
• Clinical features:   – Most common symptom is profuse and recurrent epistaxis Progressive nasal obstruction

Other features depending upon the extension of the tumour:

• Denasal speech(Rhinolalai clausa)
• Conductive hearing loss and serous otitis media due to eustachian tube blockage
• Broadening of nasal bridge
• Soft palate may bulge due to a large mass in late stages
• Proptosis
• Frog-face deformity
• Swelling of cheek
• Involvement of cranial nerves II, Ill, IV, VI

INVESTIGATIONS IN A CASE OF NASOPHARYNGEAL ANGIOFIBROMA

• Radiography:it shows a soft tissue shadow in the nasopharynx.
• Lateral view shows forward displacement of the posterior wall of maxilla.
• Angiography and CT Scan  with contrast deomonstrate the extent and vascularity of the tumor.
• Biopsy should never be attempted as it may lead to profuse bleeding.
• Instead,Excision biopsy is performed.

TREATMENT OF NASOPHARYNGEAL ANGIOFIBROMA

Surgery

• Surgical excision is the treatment of choice.
• Before surgery at least 2-3 liters of blood should be given.
• Preoperative embolization and estrogen therapy or cryotherapy reduce blood loss in surgery.
• Hypotensive Anesthesia in nasopharyngeal angiofibroma is/are given by Propofol and Phentolamine.

Approach

• Wilson’s Transpalatine approach—done for tumor confined to nasopharynx.
• Lateral rhinotomy approach—done for large tumors involving, nasal cavity, paranasal sinuses and orbit. 

Other approaches:

• Sardana’s approach – Transpalatine + Sublabial.
• Extended Lateral Rhinotomy
• Intracranial combined with Extracranial.
• Infratemporal fossa approach.

Radiation

• It is sometimes advised to reduce the vascularity of the tumor.
• It may be considered in cases with intracranial extension.

Hormonal Therapy

• It is doubtful if tumour regression occurs with this therapy.