Case reportCoblation assisted endoscopic juvenile nasopharyngeal angiofibroma resection☆
Introduction
Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular, progressively invasive, benign tumor arising almost exclusively in adolescent men. The anatomical origins of these lesions are most commonly the vascular structures of the posterolateral nasal wall and the root of the pterygoid process of the sphenoid bone. These tumors are histologically benign and account for 0.05% of all head and neck neoplasms. Often, patients present with symptoms secondary to mass effect such as nasal airway obstruction and epistaxis. Although these tumors are benign they can have intracranial/intraorbital extension and excessive bleeding.
Surgical resection has become the standard treatment. In the past, non-endoscopic approaches included transpalatal, transmaxillary, lateral rhinotomy, and midface degloving. In 1996, Kamel initially described a JNA resection done exclusively via transnasal endoscopic technique. Endoscopic resection can be assisted by image-guidance, laser, coblation or ultrasonic scalpel [1]. Though large tumor size and intracranial/infratemporal fossa extension have been cited as contraindications to endoscopic resection, significant advantages in visualization, estimated blood loss (EBL), and morbidity, makes the endoscopic approach, extremely favorable [1], [2], [3], [4], [5]. Furthermore, the final EBL has been proven to be significantly reduced with concomitant pre-operative embolization [2], [3], [4].
This is a novel approach that successfully utilizes coblation assisted exclusively endoscopic JNA excision without preoperative embolization (Cases 2 and 3), as well as the lowest reported EBL of a Radkowski IIC or larger JNA resected exclusively via endoscopic endonasal approach without preoperative embolization (Case 2) [6]. These cases utilized coblation radiofrequency technology as the main tumor dissector and were completely excised endoscopically without any external or intraoral incisions.
Section snippets
Case 1
A 23-year-old male presented with a right side vascular tumor. CT and MRI showed extension into the sphenoid sinus, Fig. 1, with bone destruction and without extension into the pterygopalatine fossa. It is staged as a Radkowski IB, which is defined as extension into the sinuses but not the pterygomaxillary fossa [6]. He underwent pre-operative embolization 48 h prior to the resection. The total surgical time was 1 h and 45 min, with a final EBL of 150 mL, yielding a blood loss per minute rate of
Discussion
Coblation technology is FDA approved for use in sinus surgery (Arthrocare, Austin, TX). One of the major advantages of the coblator device is the ability of the wand to be used to retract tumor while simultaneously dissecting, coagulating, irrigating and suctioning. Monopolar electrocautery is not effective at dissecting or debulking JNA tumor and usually causes charring. It is, however, generally effective at cauterizing larger tumor vessels, unable to be controlled with coblation cautery.
Conclusion
Coblation assisted transnasal endoscopic resection of JNA is feasible. This device can dissect through and debulk JNA tumor, despite its extreme vascularity. It can be performed with minimal morbidity and low intraoperative blood loss, even with non-embolized tumors up to Radkowski IIC. Given these cases and other experiences using the coblator in endoscopic sinus and skull base surgery [14], this device has become an important option in the armamentarium to JNA tumor removal using minimally
Disclosure
Dr. Ruiz is a speaker for ArthroCare. Drs. Saint-Victor, Tessema, Eloy and Anstead have no financial disclosures. There is no financial or material support for this research and work.
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Cited by (26)
Clinical outcomes of coblation-assisted pediatric endoscopic endonasal skull base surgery
2022, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Vascular factors are associated with JNA complication and tumor recurrence [14]. Previous researches have documented their experience with coblation for JNA resection in cases of early Radkowski stages [15–18]. Coblation can be used with minimal morbidity and low intraoperative bleeding, for non-embolized tumors of up to stage IIc [15].
Plasma ablation-assisted endoscopic excision versus traditional technique of endoscopic excision of juvenile nasopharyngeal angiofibroma
2020, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :We have used plasma ablation till stage IIC, which showed much less bleeding as compared to similar patients in the retrospective arm. In various anecdotal case series, plasma ablation assisted endoscopic excision was found to be helpful to reduce the amount of intraoperative hemorrhage and the use of total number of instruments [5–7]. Another retrospective study was published by McLaughlin et al., where 29 patients of JNA were included belonging to UPMC stage II to V, who were operated at two pediatric tertiary care hospitals.
Endoscopic Management of Vascular Sinonasal Tumors, Including Angiofibroma
2016, Otolaryngologic Clinics of North AmericaCitation Excerpt :The large size of the instrument may require an anterior maxillotomy (sublabial approach) in addition to an endonasal route. Another technique that has been used effectively for dissection of vascular tumors is coblation.7,8 Coblation uses radiofrequency energy to disrupt the tissues without generating significant heat.
Stage III nasopharyngeal angiofibroma: Improving results with endoscopic-assisted midfacial degloving and modification to the Fisch staging system
2015, Journal of Cranio-Maxillofacial SurgeryCitation Excerpt :There were no complications related to the surgical approach and no residual/recurrent lesions in any of the cases in this series with a minimum follow-up of 6 months. Various techniques suggested to reduce hemorrhage when dealing with these highly vascular tumors include ECA ligation, TAE and DPE, and use of coblation (Ruiz et al., 2012) or laser (Carrau et al., 2001) during surgery. As only temporary occlusion of the feeding vessels is needed prior to surgery, transarterial embolization with particulate agents (PVA and gelfoam) provided a cost effective option compared with liquid embolization agents.
Utility of a rotation-suction microdebrider for tumor removal in endoscopic endonasal skull base surgery
2014, Journal of Clinical NeuroscienceCitation Excerpt :Another potential disadvantage of the microdebrider, depending on the specific model utilized, is that it may not have the simultaneous capability of hemostatic cautery. For example, in hemorrhagic tumors such as juvenile nasopharyngeal angiofibromas, it is helpful to have an endoscopic bipolar or other devices such as the Coblation system (ArthroCare, Austin, TX, USA), which allows tumor debulking and cautery with a single instrument [21]. The rotation–suction microdebrider serves as an important tool in the armamentarium of an endoscopic skull base surgeon.
MRI features of sinonasal tract angiofibroma/juvenile nasopharyngeal angiofibroma: Case series and systematic review
2023, Journal of Neuroimaging
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The protocol for this study was approved by the Institutional Review Board of the University of Miami.