Introduction: Surgical resection of juvenile nasopharyngeal angiofibromas (JNA) is often complicated by excessive blood loss. Surgeons have described a range of embolization techniques to minimize intra-operative blood loss and to facilitate safe and effective resection. Direct tumoral puncture embolization with Onyx performed under endoscopic guidance is a safe and effective technique that allows for deep penetration of embolic material. Improved embolization and resulting decrease in blo od loss may contribute to improved surgical outcomes.
Objective: Description of a single institutional experience with pre-operative direct tumoral Onyx embolization of JNA.
Methods: We retrospectively reviewed the medical records of four patients who presented to a tertiary care medical center with JNA over the course of a three-month period. All patients underwent pre-operative embolization. This was performed in multidisciplinary fashion via direct tumoral puncture with Onyx under direct endoscopic visualization and fluoroscopic guidance, followed by coil embolization of the distal internal maxillary artery (Figs. 1 and 2). Initial puncture was performed by the otolaryngologist using a rigid endoscope. Setup for this procedure involved placement of nasal endoscopic equipment and hemostatic supplies into the neurointerventional suite. Endoscopic resection was performed by the same surgeon within 24 hours. Tumor characteristics, fluoroscopy time and dose, embolization details, estimated blood loss (EBL), and follow-up details were collected.
Results: All patients presented with nasal congestion or obstruction and were males aged 16-18 years of age. The average tumor volume was 18.4 cc (range 12.1 – 30.6 cc). Radkowski grades were 1b in one patient, IIa in two patients, and IIb in one patient. The average Onyx volume injected was 9.9 cc (range 3.0 – 17.4 cc). The mean total fluoroscopy dose and total fluoroscopy time was 9591 uGym2 (range 5819 – 16496 uGym2) and 57.6 min (range 44.8 – 90.3 min), respectively. All patients underwent surgical resection the following morning. The average EBL was 540 cc (range 60 – 1300 cc). No embolization-related or surgical-related complications occurred. The average follow-up period was 226.3 days. All patients had complete resections without evidence of residual tumor seen on follow-up MRI.
Conclusion: Direct tumoral puncture and embolization with Onyx is a safe and effective technique in the management of JNA. Our institutional experience suggest that several important nuances in technique as well as repetition may contribute to more effective embolization with resulting improved surgical outcomes. Further research is needed to determine the comparative efficacy of this technique as compared to standard embolization practices.
Figure 1. (A) Vascular tumoral blush from left external carotid artery injection. (B) 20G needle placed with endoscopic assistance into the posterior aspect of the tumoral blush.
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Figure 2. (A) Onyx cast at the end of the procedure. (B) Post-embolization injection of the left external carotid artery demonstrates significantly less vascular blush of the JNA.
