Endoscopic Surgery for Juvenile Angiofibroma: Critical Review of Indications After 40 Cases

Objectives: Endoscopic sinus surgery, originally adopted for the treatment of inflammatory disease, is presently a viable option in the management of selected benign and malignant tumors. The authors critically review their 12-year experience in endoscopic management of juvenile angiofibroma (JA) to assess the efficacy of this treatment modality and to more clearly define its indications and limits.

Methods: From January 1994 to December 2006, 40 patients were treated by pure endoscopic resection after vascular embolization. All patients were followed by regular endoscopic and MR examinations every 4 to 6 months for the first 5 years and subsequently at 1-year intervals to identify early residual disease.

Results: Lesions were classified according to the staging system proposed by Andrews et al (1989): stage I, n = 2; stage II, n = 25; stage IIIa, n = 10; stage IIIb, n = 3. Preoperative angiography demonstrated a unilateral blood supply in 33 (82.5%) cases, while feeding vessels from the internal carotid artery were also present in 15 (37.5%) patients. Intraoperative blood loss ranged from 80 to 1200 mL (mean, 410 mL), and intraoperative blood transfusion was required in only 1 case. Follow-up ranged from 2 to 140 months (mean, 52 mos). In 4 patients (10%), residual disease was detected by MR in spite of a negative endoscopy in 3 cases. In one patient, a 1-cm persistence involving the floor of the sphenoid sinus was endoscopically removed 36 months after previous treatment because of slight progression. The other 3 lesions, all located in the cancellous bone at the level of the root of the pterygoid process, are presently stable in size and under MR follow-up.

Conclusions: Endoscopic surgery is a safe and effective approach that allows resection of stages I to II JA with a low morbidity. The improvement of surgical instrumentation and the experience acquired during a 12-year period have undoubtedly contributed to expanding the indications for endoscopic surgery in the management of JA. Even stage IIIa-b lesions may be successfully managed unless the internal carotid artery (ICA) is encased. Management of persistent lesions may require switching to an external approach when critical areas such as the ICA, cavernous sinus, or optic nerve are involved. Follow-up by MR is crucial for early identification of residual disease that is often undetectable under endoscopic examination.