Complex Single-Stage Juvenile Nasopharyngeal Angiofibroma Resection: A Hybrid Pediatric Endoscopic Endonasal and Transmaxillary Approach.

Abstract

Background and importance: Juvenile nasopharyngeal angiofibroma (JNA) is a rare, locally aggressive vascular tumor that primarily affect adolescent males. This work illustrates a step-by-step surgical approach of an advanced-stage JNA resection in a prepubescent 5-year-old child, utilizing a hybrid endoscopic endonasal and transmaxillary approach that provides highly effective results without employing traditional open techniques.

Clinical presentation: A previously healthy 5-year-old male presented with one-year history of nasal obstruction, mouth breathing, and recurrent otitis media. The patient was found to have a large, space-occupying hypervascular tumor obstructing the nasopharynx. Preoperative radiographic imaging revealed an extensive heterogeneous, avidly enhancing mass that occupied the nasopharynx, right pterygopalatine fossa, infratemporal fossa, masticator space, and middle cranial fossa. Following superselective endovascular embolization, a hybrid endoscopic endonasal approach was planned for JNA resection, incorporating an anterior maxillotomy to allow for direct access to lateral compartments not classically amenable to conventional transnasal corridors.

Conclusion: This study demonstrates the technical feasibility of a combined endoscopic endonasal and transmaxillary approach for single-stage JNA resection with intracranial extension in pediatric patients. Key principles include tumor embolization, dynamic endoscopic visualization, avoidance of brain retraction, direct access to critical neurovascular structures, and minimizing craniofacial morbidity.