Endoscopic versus Open Approaches for Juvenile Nasopharyngeal Angiofibroma: A Meta-analysis

Objectives: To evaluate the recurrence rate of juvenile nasopharyngeal angiofibroma (JNA) after Endoscopic versus Open surgical approaches.

Study Design: Meta-analysis.

Methods: A systematic literature review of studies analyzing recurrence rate after endoscopic and open surgery for JNA was conducted using a combination of MeSH terms in Medline, Embase and Cochrane database. This review was limited to retrospective reviews in English language. Risk of bias was assessed using the Cochrane Q test. Chi2 and I2 statistics were calculated to determine the presence and extent of statistical heterogeneity.

Eligibility Criteria: Studies with 10 patients or more, analyzing recurrence rate after Endoscopic and Open surgical approaches for JNA with at least a mean follow-up of 2-years.

Evaluation Method: Study selection, independent review by 2 authors using predefined data fields and risk of bias scoring were performed independently by two authors in concordance with the PRISMA statement.

Results: Among 9 studies including 375 patients from 1981 to 2012, with a mean follow-up of 49.4 months, a total of 92 patients (24.5%) had recurrence. Using the DerSimonian-Laird random-effects method, the total estimated effect size was -0.16; indicating that endoscopic resection gives a better chance of non-recurrence over open resection of JNA (95% CI, −0.25 and −0.06). When analyzing tumor by stage (Radkowski I–IIIB, n = 299), the endoscopic approach seems to be superior independent of tumor stage. This is proven as the difference between the endoscopy recurrence rate and the open recurrence rate is statistically significant (2 vs. 17% for tumors stage I–IIA and 26 vs. 32% for tumor stage IIB–IIIB for endoscopic and open approaches, respectively, p < 0.05). There was no statistically significant difference in heterogeneity between studies when using the Cochrane Q test (15.2, p < 0.05) meaning that these findings are related to random effect rather than a selection bias.

Conclusion: The use of endoscopic approaches to treat JNA have a significantly lower recurrence rate when compared with open approaches. Independent of tumor size and advanced disease, endoscopic approaches should be the standard of care to surgically treat a JNA, specially for smaller tumors.

Keywords: juvenile nasopharyngeal angiofibroma, skull base neoplasm, endoscopic anterior skull base tumor resection, craniofacial approach to the skull base, endoscopic endonasal surgery, neoplasm recurrence, treatment outcome