asopharyngeal

Angiofibroma
A
i fib
Dr. Vishal Sharma

Definition
Benign tumor of nasopharynx (?), locally
nvasive, extremely vascular & occurs in

adolescent males.
amartomatous nidus of vascular tissue,
ependent on testosterone.

Synonyms: nasopharyngeal fibroma,

angiofibroma

Site of origin
Arises in posterior nasal cavity, near superior
border

sphenopalatine

Sphenopalatine foramen

Pathology
ross: Sessile, bi-lobed, rubbery, red-pink or
ray

colour.

istology: Encapsulated, composed of vascular

ssue & fibrous stroma. Vessels are thin-walled,
ck elastic fibers & smooth muscle (this leads

o uncontrolled bleeding).

Histopathology

Small tumour

Nasal cavity

Nasal cavity & P.N.S.

Nasopharynx

Pterygopalatine fossa

Infratemporal fossa

Infratemporal fossa

Cheek

Orbit

Sphenoid sinus

Middle cranial fossa

Pituitary & Cavernous sinus

Spread
nterior: Nasal cavity + paranasal sinus

osterior: Nasopharynx
ateral: goes to Pterygopalatine fossa
1. Infratemporal fossa cheek
2. Inferior orbital fissure orbit

Spread

uperior: 1. Sphenoid sinus

Middle cranial fossa
Cavernous sinus
Optic chiasma
Pituitary fossa
2. Skull base
Middle cranial fossa

Symptoms

Nasal obstruction (80-90%) with denasal

speech (rhinolalia clausa)

Epistaxis (50-60%): Persistent, Painless,

Profuse, Paroxysmal, Unprovoked

Headache (25%)

Facial swelling (20%): cheek & palatal swelling

Facial swelling

Signs
asal or Nasopharyngeal mass (80%)

rog-face deformity:
+
idge broadening
titis media with effusion:
to

blockage

rismus: involvement of pterygoid muscle

volvement of II, III, IV, VI cranial nerve

C.T. scan P.N.S. with contrast

xtent of tumor
nterior bowing of
osterior maxillary
all (Miller Holmans
ntral sign)
umor enhancement
one destruction

Other Investigations
.R.I.: for intra-cranial involvement
igital Subtraction Angiography (D.S.A.):
. extent of tumor
. tumour blush (due to increased vascularity)
. feeding arteries for embolization
iopsy: contraindicated (profuse bleeding)

Magnetic Resonance Imaging

D.S.A. before embolization

D.S.A. after embolization

Differential diagnosis
Rhabdomyosarcoma
Antrochoanal polyp
Teratoma
Dermoid
Encephalocoele
Inverting papilloma
Squamous cell carcinoma

Staging
tage I: Tumor limited to nasal cavity or
nasopharynx with no bony destruction
tage II: Tumor invading pterygopalatine
fossa or paranasal sinuses
tage III: Tumor invading infratemporal
fossa or orbit or parasellar region
tage IV: Tumor invading cavernous sinus
or optic chiasma or pituitary fossa

Pre-op reduction of tumor

vascularity

Embolization of feeding arteries: with Gelfoam

Oestrogen therapy: Diethylstilbestrol

.5

mg orally t.i.d. for 3 - 6 wk)

Testosterone receptor blocker: Flutamide
Pre-operative radiotherapy
Cryotherapy of tumor

Trans-palatal approach

Trans-palatal approach

Trans-palatal approach

Sardanas approach

Endoscopic approach

Lateral rhinotomy approach

Lateral rhinotomy approach

Midfacial degloving

Denkers incision

ldwell Luc incision extended medially till midline

Le Fort 1 osteotomy

nfratemporal fossa approach

Anterior subcranial approach

Surgical approaches
Trans-palatal approach (Wilson)
small tumour in nasopharynx
Sublabial + Trans-palatal approach (Sardana)
large tumour of nose + PNS + nasopharynx
Intranasal endoscopic approach
small tumour in nose / PNS / nasopharynx

Surgical approaches
Transmaxillary approach via:
Extended lateral rhinotomy incision
Midfacial degloving incision
Denkers extended Caldwell-Luc incision
Le Fort 1 osteotomy approach
Done for extension into pterygopalatine fossa

Surgical approaches
Infratemporal fossa approach (Fisch)
extension into infratemporal fossa
Anterior subcranial approach
intracranial & orbital extension
Image-guided, endoscopic, laser-assisted
removal (latest): small / medium size tumors

Surgical specimen

Surgical specimen

roton Stereotactic Radiation

Therapy (P.S.R.T.)
onym: Gamma knife surgery
d for: . Intracranial
2. Recurrence after surgery
ingle relatively high dose of radiation delivered
recisely to a small area to kill tumor cells
inimal injury to adjacent nerves & brain tissue

Stereotactic Radiotherapy

Thank You