Standardization of Embolization Technique for Juvenile Nasopharyngeal Angiofibroma

Objective: Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular tumor. Although embolization can reduce intraoperative blood loss, nontarget embolization resulting in cranial nerve injury or even stroke is a potential risk. Neurophysiologic monitoring may be valuable as a means to mitigate these risks. There is currently no standardized guideline for type of embolic agent and use of neuromonitoring. This study identified practice patterns for JNA embolization at a tertiary care institution regarding preference for embolic agent and use of neuromonitoring. Other tertiary centers nationally were surveyed to assess practice patterns across different institutions.

Methods: A retrospective chart review was performed for patients undergoing embolization for JNA from July 2011 to May 2021 at a single tertiary care center. Data collected included the following: presenting symptoms, prior history of treatment, imaging results, UPMC staging, provider, arterial blood supply to the JNA, embolic agent, residual vascularity (defined as >5%), neuromonitoring and results if applicable, and complications following embolization. A comprehensive survey delineating three cases was distributed to various providers at multiple institutions who routinely perform JNA embolizations. Provider demographic information as well as preferred embolic agent and use of neuromonitoring was recorded for each case presented.

Results: Of the 48 patients, 42 (88%) presented with epistaxis and nasal obstruction and 9/39 (19%) patients had prior resection. UPMC staging revealed 9/48 (19%) stage I, 2/48 (4%) stage II, 13/48 (27%) stage III, 7/48 (15%) stage IV, and 15/48 (33%) stage V. Arterial supply was via the external carotid (ECA) in 18/48 (38%) and through both the ICA and ECA in 30/48 (62%). Blood supply was unilateral in 20/48 (42%) and bilateral in 28/48 (58%). Residual vascularity was present in 32/48 (67%) of cases. General anesthesia was used in 47/48 (98%). Onyx was the most common embolic agent used in 35/48 (73%), followed by particles in 4/48 (8%), and a combination of onyx and particles in 8/48 (17%). Somatosensory evoked potentials (SSEP) and electroencephalography (EEG) was the most common neuromonitoring used in 33/48 (69%). Neuromonitoring was not used in 11/48 (23%) of patients. Complications included cerebrovascular accident in 1/48 (2%), and temporary neurological deficits in 5/48 (10%). There were no recorded events during cases with neuromonitoring. Provider preference for embolic agent was statistically significant (p = 0.003); however, use of neuromonitoring was not statistically significant. UPMC staging, laterality of blood supply, and year of procedure had no association with embolic agent or whether neuromonitoring was used. Regarding the survey distributed nationally, we found that practice patterns varied depending on provider, even when presented with the same case scenario.

Conclusion: There are strong provider-dependent preferences for the type of embolic agent and use of neuromonitoring in embolization of JNA. Standardization of embolization technique may eliminate provider-dependent bias and hopefully minimize morbidity associated with the procedure. Future directions include multi-institutional studies to assess for factors associated with complications in order to identify areas for potential standardization.

Publication History

Article published online:
15 February 2022