Juvenile Nasopharyngeal Angiofibromas: Blood, Sweat, Tears and Fresh Ideas-how we do it

Aim Introduction: Management of advanced juvenile nasopharyngeal (JNA) angiofibroma is plagued with surgical frustration, largely because of its propensity for haemorrhage. To minimise blood loss and the need for allogenic blood transfusion we routinely use preoperative embolisation and intra-operative cell salvage. Although endoscopic surgery is now standard of care in many centres, the resection of large tumours with infratemporal fossa extension can be challenging. A combined open and endoscopic approach is often reported for very large tumours if dissection around the tumour is not possible. We have found that the endoscopic Denker's approach, together with the use of cell salvage allows for complete endoscopic resection without the need for any external procedures. Cell salvage allows for more intra-operative blood loss with a rare need for allogenic transfusion. Method: We describe the current treatment protocol for all JNA tumours at our institute showing that complete endoscopic resection is possible using the Denker's approach together with intra-operative cell salvage. Aim: This paper explains how adequate endoscopic access may be gained to dissect around these tumours without the need for debulking. The added benefit of cell salvage during endoscopic resection is discussed.