Evolving Surgical Approaches in Juvenile Nasopharyngeal Angiofibroma: A Comprehensive Review

In 1998, Choremis J. and Frenkiel S. reported a 16-yearold’s case of diagnosed and treated Juvenile nasopharyngeal angiofibroma (JNA) that was managed successfully to full recovery without any further complications [1]. JNA is a rare tumor condition that affects prepubertal males between 7 and 19 years. The mean age among its patients is 14 years. It often includes benign bleeding and can destroy nasopharyngeal tissue. Adolescents and early adults with this condition often present with nasal obstruction and spontaneous nosebleeds. However, since 1998, the treatment and management of JNA has changed significantly. This narrative review discusses the case of the sixteen-year-old concerning modern surgical procedures and appraises the efficacy of advances in JNA, adding to the current stock of knowledge on evidence-based therapy for the tumor. The review focuses on whether or not the surgery was a success, the current approaches to JNA removal, and how to successfully manage postoperative patients.

To carry out this narrative review, the research relies on two main information categories: the research by Choremis and Frenkiel (1998) and additional up-to-date articles by contemporary authors on JNA surgical interventions, procedures, and success rates. The review used several libraries, mainly online, to find the necessary information and comparative reviews and reports from high-quality research articles (herein rated as strong or weak, depending on the evidence they rely on). The narrative review is limited to articles not older than 10 years (since 2013) and used the following leading search words: Juvenile Nasopharyngeal Angiofibroma, modern JNA Diagnosis approaches, Treatment, Genetic and Molecular Research, Imaging Modalities. Only English publications were considered to encourage consistency and avoid transliteration issues. The search was conducted between November 1 and 2nd and the review report was completed on November 2nd.

General Procedure

The reviewed case study uses a direct intervention method where the sixteen-year-old male is diagnosed with painful nose bleeding. Contemporary authors and research agree with the implied aggression of JNA among adolescents and teens, noting that the often spreads to the skull’s base and sometimes into the cranium [2]. Both children and early adults experiencing bleeding due to the JNA are still given the balloon-packing first aid method, showing the resilience of this early intervention [3]. According to Pandelaki et al. [4] embolization is still used to successfully and effectively arrest, reduce, and make less damaging bleeding after JNA operation through catheterized embolization. Other researchers have agreed with the resiliency of embolized bleeding intervention in JNA therapy through the removal of the tumor, more so, when the tumor has grown thin-layered bleeding blood vessels [2,5,6].

General Diagnosis

In the case study, a biopsy confirms CT scans and MRI suspicions for nasopharyngeal lesions, typical of JNA. This was upon a rigorous medical history taking that led to suspicions of JNA as the cause of the bleeding and the near-blockage tumor. According to the contemporary evidence-based research and practice in JNA interventions, history-taking has remained the first stage in diagnosing JNA among children and teens [2]. Many of those who present with JNA have a family history of either JNA or any of the correlated conditions. Contemporary methods use endoscopy or the use of an endoscope, a thin, flexible tube with a light and camera attached to it. The endoscope is inserted through the nostrils to examine the nasal passages, nasopharynx, and other areas of the upper respiratory tract. The endoscope observes the presence of a fleshy mass or tumor within the nasopharynx and hence, endoscopic examination helps assess the location, size, and extent of the tumor through non-invasive physical observations [7-9]. For higher certainty as to whether or not historiography leads to JNA, CT scans are used to increase both the details and the angles from which the tumor is observed. This contemporary approach leads to revelations of the exact location and extent of the JNA, as well as any bone erosion or remodeling caused by the tumor [2]. It also helps in differentiating JNA from other conditions with similar presentations. Further, MRI adds highly detailed images and localizes the tumor as viewed from the head and neck areas, helping to observe whether and the intensity of any other tissue damage. MRI is very useful for assessing soft tissues, which makes it valuable for detecting and characterizing JNA [2]. This can add to details differentiating JNA from similar conditions. It can provide information about the vascular nature of the tumor which determines the extent of bleeding expected, its precise location which informs the type of incisions and resections to be done, and its relationship to nearby structures such as the palate and the cranium. MRI can help confirm the diagnosis and guide treatment decisions. As seen in the case study, a differential diagnosis helps to rule out other conditions such as lymphoma or rhabdomyosarcoma and the surgeon effectively intervenes for the observed tumor with certainty. This approach involves two types of diagnosing and intervening for JNA that are still used to date: historiography and differential diagnoses [8].

Biopsy Diagnosis versus Imaging

Differential diagnosis is common in JNA diagnosis. One of the approaches for differential diagnosis and confirmation for JNA is biopsy. According to the current article, [1] a biopsy was mandated to ensure that the tissue observed was a JNA lump. This led to bleeding which the surgeons contained through pressure packing. This is invasive in a way as the procedure involves the removal of a small tissue, interfering with the lamp before its nature is confirmed. Should the lump be found non-JNA and should the surgeon recommend not removing it, the biopsy would have been unnecessary. However, in 1998, a biopsy was necessary to be certain that the surgeon was dealing with a tumor JNA and not any other condition [1,2]. In contemporary practice, however, a biopsy is rare for JNA and its allied conditions since medicine has advanced to include non-invasive observations, localization, and differentiation methods using highly definitive CT scanning and MRI technologies. This aspect underscores the significant changes between 1998 and the present, a progressive achievement in medical practice generally and surgery in particular. CT scans and MRIs have grown to confirm the presence and nature of vascular systems in JNA tissue, one of the primary reasons why biopsies are needed post-imaging. This helps to reduce the risk of unnecessary exposure to preoperative bleeding and reduction of postoperative bleeding since the surgeon knows in advance the level of vascularization [2,9].

Surgery Access

The current case involved trans palatal access and removal of the tumor. This is a surgery procedure where the upper soft palate is incised to access the tumor and the tumor is excised from its nearby tissues, carefully removing all affected tissue to avoid regrowth. Preoperative embolization is deployed against bleeding and the surgeon uses sutures to close up the opened palate tissue. The case used electrocauterization with pressure packing to arrest bleeding and successfully recovered in five days, released from the hospital. This procedure, however, is almost becoming obsolete in common JNA operations [10]. Contemporarily, endoscopic removal of the tumor tissue through the nose is preferred due to improved technologies (endoscopic surgery) and the increasing preference for non-invasive surgical approaches [5,11].

Success Rate

The patient recovered with uneventful management in a short time-five days. A 2-month postoperative review indicates there are no residual nasopharynx tumors and that the patient has been well-healed. A monthly laryngoscopy for six months confirms safe recovery. The authors also note that as of its publication, there was a recurrence rate of 5-11% [1]. While the recovery rate appears to remain with modern technologies, the recurrence rate differs significantly. Leong et al. noted a 18% of the patients resulted in recurrence while Fang et al. rated it at 38.7% [9,10]. Other studies have shown a recurrence rate between 20% and 55% showing that there is no clear understanding of the rate of recurrence and the success of JNA surgery through endoscopy [9,10].

This narrative review establishes several coincidences between the 1998 article and contemporary medical practices with JNA. JNA is aggressive among males between 7 and 19 years old. It is removed through surgical incision and resection to remove the tumor lump using preoperative embolization in the absence of intracranial involvement. The successful intervention for the 16-year-old shows that proper history, clinical and imaging examinations, and precise removal can lead to a one-off operation and successful recovery. On the other hand, a review of contemporary research and evidence shows that JNA excision tends towards endoscopic surgery and non-invasive or minimally invasive surgical methods, improving its intervention procedures. Also, the evidence indicates a higher recurrence rate than previously thought, which implies extra vigilance among practitioners and healthcare workers in charge of postoperative JNA patients. The covetable appraisal of CT and MRI imaging technology as replacing the formally practiced biopsies shows notable milestones in improving surgical processes for enhanced comfort and success of excisions. This can increase consumer trust in modern technologies. Therefore, this review adds to the existing research on the efficacy of endoscopic interventions of JNA.

None.

No conflict of interest.

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