Nasopharyngeal

Angiofibroma
 Definition
 Benign tumor of nasopharynx (?), locally
invasive, extremely vascular & occurs in
adolescent males.

 Hamartomatous nidus of vascular tissue,

dependent on testosterone.

 Synonyms: nasopharyngeal fibroma,

angiofibroma
 Site of origin
Arises in posterior nasal cavity, near superior
border of sphenopalatine foramen
Sphenopalatine foramen
 Pathology
Gross: Sessile, bi-lobed, rubbery, red-pink or

gray in colour.

Histology: Encapsulated, composed of vascular

tissue & fibrous stroma. Vessels are thin-walled,

lack elastic fibers & smooth muscle (this leads

to 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
Anterior: Nasal cavity + paranasal sinus

Posterior: Nasopharynx

Lateral: goes to Pterygopalatine fossa 

1. Infratemporal fossa  cheek

2. Inferior orbital fissure  orbit

 Spread
Superior: 1. Sphenoid sinus
 Middle cranial fossa
 Cavernous sinus
 Optic chiasma
 Pituitary fossa
2. Skull base
 Middle cranial fossa
 Symptoms
1. Nasal obstruction (80-90%) with denasal

speech (rhinolalia clausa)

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

Profuse, Paroxysmal, Unprovoked

3. Headache (25%)

4. Facial swelling (20%): cheek & palatal swelling

Facial swelling
 Signs
1. Nasal or Nasopharyngeal mass (80%)
2. Frog-face deformity:
proptosis + nasal
bridge broadening
3. Otitis media with effusion:
due to E.T. blockage
4. Trismus: involvement of pterygoid muscle
5. Involvement of II, III, IV, VI cranial nerve
 C.T. scan P.N.S. with contrast
 Extent of tumor

 Anterior bowing of
posterior maxillary
wall (Miller Holman’s
antral sign)

 Tumor enhancement

 Bone destruction
 Other Investigations
 M.R.I.: for intra-cranial involvement

 Digital Subtraction Angiography (D.S.A.):

a. extent of tumor

b. tumour blush (due to increased vascularity)

c. feeding arteries for embolization

 Biopsy: 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
Stage I: Tumor limited to nasal cavity or
nasopharynx with no bony destruction

Stage II: Tumor invading pterygopalatine

fossa or paranasal sinuses
Stage III: Tumor invading infratemporal
fossa or orbit or parasellar region
Stage IV: Tumor invading cavernous sinus
or optic chiasma or pituitary fossa
 Pre-op reduction of tumor
vascularity
1. Embolization of feeding arteries: with Gelfoam

2. Oestrogen therapy: Diethylstilbestrol (2.5 - 5

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

3. Testosterone receptor blocker: Flutamide

4. Pre-operative radiotherapy

5. Cryotherapy of tumor
Trans-palatal approach
Trans-palatal approach
Trans-palatal approach
Sardana’s approach
Endoscopic approach
Lateral rhinotomy approach
Lateral rhinotomy approach
Midfacial degloving
 Denker’s incision

Caldwell Luc incision extended medially till midline

Le Fort 1 osteotomy
Infratemporal fossa approach
Anterior subcranial approach
 Surgical approaches
1. Trans-palatal approach (Wilson)

small tumour in nasopharynx

2. Sublabial + Trans-palatal approach (Sardana)

large tumour of nose + PNS + nasopharynx

3. Intranasal endoscopic approach

small tumour in nose / PNS / nasopharynx

 Surgical approaches
4. Transmaxillary approach via:

 Extended lateral rhinotomy incision

 Midfacial degloving incision

 Denker’s extended Caldwell-Luc incision

 Le Fort 1 osteotomy approach

Done for extension into pterygopalatine fossa

 Surgical approaches
5. Infratemporal fossa approach (Fisch)

extension into infratemporal fossa

6. Anterior subcranial approach

intracranial & orbital extension

7. Image-guided, endoscopic, laser-assisted

removal (latest): small / medium size tumors

Surgical specimen
Surgical specimen
Proton Stereotactic Radiation
Therapy (P.S.R.T.)
Synonym: Gamma knife surgery

Used for: 1. Intracranial extension

2. Recurrence after surgery

 Single relatively high dose of radiation delivered

precisely to a small area to kill tumor cells

 Minimal injury to adjacent nerves & brain tissue

Stereotactic Radiotherapy
Thank You