Endoscopic Modified Denker's Approach for the Treatment of Juvenile Nasopharyngeal Angiofibroma

Abstract

Juvenile nasopharyngeal angiofibroma is a benign vascular lesion with propensity of bony erosion leading to skull base involvement and intracranial extension. It involves multiple compartments which are difficult to access surgically. With surgical expertise endoscopic resection of angiofibroma has become the preferred choice of surgical management. This article presents our experience with endoscopic approach for angiofibroma and establishes the modified Denker's procedure as a effective approach for removal of tumor. A prospective case study was done on 25 cases of juvenile nasopharyngeal angiofibroma treated surgically by endonasal endoscopic modified Denker's approach in the department of ENT at BJ Medical College, Ahmedabad over a period of 4 years from January 2015 to January 2019. This technique was used up to Fisch stage 3b with extension up to infratemporal fossa. Using this technique no major recurrence or major morbidity was observed and did not produce any late serious complications. The endoscopic technique allows the surgeon to achieve an extensive exposure of the sinuses and control of the sphenopalatine and internal maxillary arteries without the risk of palatal dysfunction, oronasal fistula, or facial scarring. In addition, the modified Denkers approach can be an effective and less mutilating technique in managing recurrences.

Keywords: Angiofibroma; Endoscopic; Modified Denker’s.

Fig. 1

Intranasal incisions are made with cautery along the dotted lines and carried through the periosteum. Specifically, an inferior incision is made at the junction of the nasal floor and lateral nasal wall, followed by a superior incision along the lateral nasal wall and anteriorly overlying the pyriform aperture. IT, inferior turbinate; M, middle turbinate; NF, nasal floor; NS, nasal septum [9]

Fig. 2

a Elevating the mucosa off of the maxilla using a suction Freer. b Elevating the mucosa off of the lateral nasal wall. The nasolacrimal duct is cut sharply once exposed [9]

Fig. 3

Expose the maxillary sinus. AMW, anterior maxillary sinus wall; IT, inferior turbinate; LNW, lateral nasal wall; NLD, nasolacrimal duct; NS, nasal septum; V2, infraorbital nerva [9]

Fig. 4

Pie diagram showing side of presentation of JNA

Fig. 5

Distribution of patients according to Fisch classification

Fig. 6

Preoperative CT scan of the patient with JNA in coronal, sagittal and axial cuts respectively

Fig. 7

Post operative CT scan of the patient in coronal, sagittal and axial cuts respectively

Fig. 8

Resected specimen by endoscopic modified Denker’s approach