Direct Puncture Embolization for Endonasal Resection of Juvenile Nasopharyngeal Angiofibroma Supplied by Internal Carotid Artery

Introduction: Juvenile nasopharyngeal angiofibromas (JNAs) have a propensity for major blood loss when approached surgically. Use of preoperative transarterial (TA) or direct tumor puncture (DTP) embolization has been shown to reduce blood loss during resection. It is critical to determine the embolization technique that best suits a specific tumor prior to resection to optimize surgical conditions by minimizing intraoperative bleeding. We present a case report that underscores the importance of this treatment approach and begs for the development of such an algorithm.

Case Presentation: A 13-year-old male patient presented emergently with severe epistaxis refractory to nasal packing. Endoscopic exam revealed a vascular mass filling the right nasal cavity. CT and MRI demonstrated a large hypervascular tumor consistent with a JNA that was centered in the right sphenopalatine fossa and filled the infratemporal fossa/nasal cavity/nasopharynx. There was significant extension and compression into the posterior orbit/orbital apex as well as to the anterior cavernous sinus. He underwent preoperative embolization (TA) of the tumor that left a significant residual ICA supply, making this a UPMC stage 5 tumor. The patient underwent an expanded endonasal approach (EEA) supplemented by a sublabial transmaxillary approach that was aborted after ~70% tumor resection due to excessive blood loss. One month later he returned for preoperative embolization performed by direct tumor puncture (Onyx) with intermittent right ICA occlusion leading to dramatic reduction in residual tumor vascularity. This was followed by successful gross total tumor resection (GTR).

Discussion: Preoperative embolization can aid in surgical management of JNAs by reducing tumor vascularity thereby decreasing intraoperative blood loss. JNAs typically draw the majority of their blood supply from the external carotid artery system that traditional TA embolization is able to effectively manage. Larger tumors have an increased propensity to draw a more significant component of their blood supply from the internal carotid artery system for which TA embolization is less effective. In the presented case, DTP embolization was shown to successfully manage the residual ICA supply that had precluded GTR at the initial staged surgery.

Conclusion: In higher stage JNAs with significant ICA supply, DTP embolization should be strongly considered as a devascularization method either in isolation or concurrent with TA embolization.