Removal of Intracranial Extension of Juvenile Nasopharyngeal Angiofibroma by the Transfacial Approach

Objectives: Although benign, juvenile nasopharyngeal angiofibromas (JNA) can spread aggressively into the skull base. Most challenging are the digitations, which spread intracranially. Those warrant for some authors a combined approach. In our series, the anterior extension to the cavernous sinus through the orbital apex is the most common intracranial extension. In order to limit surgical iatrogeny and morbidity, the aim of this work is to analyze whether the exclusive transfacial approach can handle this extension.

Methods: Retrospective study based on the 29 cases of JNA treated in our institution during the last 6 years. All were embolized preoperatively and passed an early postoperative CT scan. Follow-up was based on repeated endoscopy, CT, and/or MRI.

Results: Eleven cases with intracranial extension (type IIIb Radkowski staging) were treated during the last 6 years (38%). Among these, 10 had an anterior cavernous sinus invasion (35%). A transfacial approach was performed in all cases, combined with a pterional approach in 2 cases because of massive middle fossa involvement. Tumor extension could be removed totally in 8 out of 10 cases, which are the cases removed through an exclusive transfacial approach. The technique is described. Morbidity was related to a III palsy which recovered within a few weeks in 1 case, and to secondary arteritis of the ICA with subsequent blindness and hemiplegia which occurred in another case with massive skull base and intradural invasion.

Conclusions: Invasion of the cavernous sinus through the inferior orbital fissure and orbital apex is the most frequent intracranial extension of JNA in this series. Removal can be achieved in most cases through an anterior approach and does not warrant a combined approach.