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NASOPHARYNGEAL ANGIOFIBROMA Tr ầ n T h ị Đ ỗ Q u y ê n - N T 44 INTRODUCTION  The most common of the benign nasopharyngeal neoplasm  0,5% of all head and neck tumours  Young males (high androgen receptor (AR) expression => JNA is androgen dependent) HISTOPATHOLOGY  Benign but highly vascular tumour  May be locally aggressive  Non-encapsulated, red to gray colored mass  A thick vascular network composed of irregular blood vessels within a connective fibrocellular tissue, rich in collagen and fibroblasts  Vessels are extremely variable in size and shape, without elastic fibers in their walls and with a frequently incomplete muscolar layer ORIGIN - Sphenopalatine foramen - Pterygopalatine fossa - Choana - Nasopharynx CLINICAL PRESENTATION  Obstructive symptoms  Rhinorrhea  Chronic otomastoiditis  Headache, facial pain: secondarily to the blockage of paranasal sinuses  Proptosis and alteration of the vision: involvement of the orbit  Swelling of the cheek STAGING Sessions classification: • Stage I   Ia: limited to nasal cavity/nasopharynx • Stage II   IIa: minimal extension through sphenopalatine foramen into pterygomaxillary fossa Ib: extension into one or more paranasal sinuses IIb: fills pterygomaxillary fossa bowing the posterior wall of the maxillary antrum anteriorly or extending into the orbit via the inferior orbital fissure  IIc: extends beyond pterygomaxillary fossa into infratemporal fossa  • Stage III: intracranial extension NASAL ENDOSCOPY  May reveal a pale reddish mass IMAGING FEATURE  Hollman - miller sign (a) Axial enhanced CT scan demonstrating a large avidly enhancing lesion from a juvenile angiofibroma There is widening of the sphenopalatine foramen (arrow) with marked distortion of the posterior wall of the maxillary antrum (b) A selective angiogram of the right external carotid artery shows a strong vascular blush in the vicinity of the internal maxillary artery (arrow) territory Fig Nasopharyngeal angiofibroma (a) axial gradient echo and (b) axial T2-weighted MR imaging of a left-sided tumor growing anteriorly into the nasal cavity (black arrow), dislocating the ipsilateral maxillary sinus anteriorly (white arrow) and growing into the masticator space (black arrowhead).The rich vascularity of the tumour gives rise to the typical small dotted flow voids, responsible for the salt and pepper appearence ANGIOGRAPHY (DSA)  Useful in both defining the feeding vessels and in preoperative embolization • External carotid artery: the majority • Internal maxillary artery • Ascending pharyngeal artery • Palatine arteries • Internal carotid artery: less common, usually in larger tumours • Ophthalmic artery Differential diagnosis  Nasopharyngeal carcinoma  Rhabdomyosarcoma TREATMENT  Embolism  Selective preoperative embolism of arterial feeding vessels has significantly decreased intraoperative hemorrhage facilitating resection of larger tumors  Embolism is typically performed 24–72  hours prior to resection  Surgery  Surgical resection after embolism is the treatment of choice and may be performed using and open or endoscopic approaches  Radiation Therapy  May be an option when surgery is impossible or incomplete CONCLUSION  Angiofibroma is the most common of the benign nasopharyngeal neoplasm  Young men  Origin: sphenopalatine foramen, pterygopalatine fossa, choana  Hypervascular tumor, Holmann-Miller sign ... HISTOPATHOLOGY  Benign but highly vascular tumour  May be locally aggressive  Non-encapsulated, red to gray colored mass  A thick vascular network composed of irregular blood vessels within... ANGIOFIBROMA Tr ầ n T h ị Đ ỗ Q u y ê n - N T 44 INTRODUCTION  The most common of the benign nasopharyngeal neoplasm  0,5% of all head and neck tumours  Young males (high androgen receptor... a connective fibrocellular tissue, rich in collagen and fibroblasts  Vessels are extremely variable in size and shape, without elastic fibers in their walls and with a frequently incomplete muscolar layer