Skip to main content Accessibility help

In defence of transpalatal, transpalatal-circumaxillary (transpterygopalatine) and transpalatal-circumaxillary-sublabial approaches to lateral extensions of juvenile nasopharyngeal angiofibroma

  • A Mishra (a1), S C Mishra (a1) (a2), V Verma (a1), H P Singh (a1), S Kumar (a1), A M Tripathi (a1), B Patel (a1) and V Singh (a1)...



Juvenile nasopharyngeal angiofibroma often presents with lateral extensions. In countries with limited resources, selection of a cost-effective and least morbid surgical approach for complete excision is challenging.


Sixty-three patients with juvenile nasopharyngeal angiofibroma, with lateral extensions, underwent transpalatal, transpalatal-circumaxillary (transpterygopalatine) or transpalatal-circumaxillary-sublabial approaches for resection. Clinico-radiological characteristics, tumour volume and intra-operative bleeding were recorded.


The transpalatal approach was suitable for extensions involving medial part of pterygopalatine fossa; transpalatal-circumaxillary for extensions involving complete pterygopalatine fossa, with or without partial infratemporal fossa; and transpalatal-circumaxillary-sublabial for extensions involving complete infratemporal fossa, even cheek or temporal fossa up to zygomatic arch. Haemorrhage was greatest with the transpalatal-circumaxillary-sublabial approach, followed by transpalatal approach and transpalatal-circumaxillary approach (1212, 950 and 777 ml respectively). Tumour size (volume) was greatest with the transpalatal-circumaxillary approach, followed by transpalatal-circumaxillary-sublabial approach and transpalatal approach (40, 34 and 29 mm3). There was recurrence in three cases and residual disease in two cases. Long-term morbidity included small palatal perforation (n = 1), trismus (n = 1) and atrophic rhinitis (n = 2).


These modified techniques, performed with endoscopic assistance under hypotensive anaesthesia, without embolisation, offer a superior option over other open procedures with regard to morbidity and recurrences.


Corresponding author

Address for correspondence: Dr Anupam Mishra, Department of Otorhinolaryngology, King George Medical University, Lucknow, India E-mail:


Hide All
1 Chew, CT. Nasopharynx (the postnasal space). In: Kerr, AG, Groves, J, eds. Scott-Brown's Otolaryngology: Rhinology (Volume IV), 5th edn. London: Butterworth, 1987
2 Kamel, R. Transnasal endoscopic surgery in juvenile nasopharyngeal angiofibroma. J Laryngol Otol 1996;110:962–86
3 Radkowski, D, McGill, T, Healy, GB, Ohlms, L, Jones, DT. Angiofibroma: changes in staging and treatment. Arch Otolaryngol Head Neck Surg 1996;122:122–9
4 Mishra, SC, Shukla, GK, Bhatia, N, Pant, MC. A rational classification of angiofibromas of the postnasal space. J Laryngol Otol 1989;103:912–16
5 Sardana, DS. Nasopharyngeal fibroma: extension into cheek. Arch Otolaryngol 1965;81:584–8
6 Mishra, SC, Shukla, GK, Bhatia, N, Pant, MC. Angiofibromas of the postnasal space: a critical appraisal of various therapeutic modalities. J Laryngol Otol 1991;105:547–52
7 Howard, DJ, Lloyd, G, Lund, V. Recurrence and its avoidance in juvenile angiofibroma. Laryngoscope 2001;111:1509–11
8 Cansiz, H, Güvenç, MG, Sekercioğlu, N. Surgical approaches to juvenile nasopharyngeal angiofibroma. J Craniomaxillofac Surg 2006;34:38
9 Howard, DJ, Lund, VJ. The midfacial degloving approach to sinonasal disease. J Laryngol Otol 1992;106:1059–62
10 Lowlicht, RA, Jassin, B, Kim, M, Sasaki, CT. Long-term effect of Le Fort I osteotomy for resection of juvenile nasopharyngeal angiofibroma on maxillary growth and dental sensation. Arch Otolaryngol Head Neck Surg 2002;128:923–7
11 Benjamin, S, Stella, C, Ziv, G, Chaushu, G, Fliss, DM. Effects of the subcranial approach on facial growth and development. Otolaryngol Head Neck Surg 2007;136:2732
12 Lewark, TM, Allen, GC, Chowdhury, K, Chan, KH. Le Fort I osteotomy and skull base tumors: a pediatric experience. Arch Otolaryngol Head Neck Surg 2000;126:1004–8
13 Janecka, IP, Nuss, DW, Sen, CN. Facial translocation approach to the cranial base. Acta Neurochir Suppl (Wien) 1991;53:193–8
14 Gates, GA. The lateral facial approach to the nasopharynx and infratemporal fossa. Otolaryngol Head Neck Surg 1988;99:321–5
15 Zhang, M, Garvis, W, Linder, T, Fisch, U. Update on the infratemporal fossa approaches to nasopharyngeal angiofibroma. Laryngoscope 1998;108:1717–23
16 Browne, JD, Jacob, SL. Temporal approach for resection of juvenile nasopharyngeal angiofibromas. Laryngoscope 2000;110:1287–93
17 Bales, C, Kotapka, M, Loevner, LA, Al-Rawi, M, Weinstein, G, Hurst, R et al. Craniofacial resection of advanced nasopharyngeal angiofibroma. Arch Otolaryngol Head Neck Surg 2002;128:1071–8
18 Haines, SJ, Duvall, AJ. Transzygomatic and transpalatal excision of juvenile nasopharyngeal angiofibroma with intracranial extension. In: Sekhar, LN, Janecka, IP, eds. Surgery of Cranial Base Tumors. New York: Raven Press, 1993;477–84
19 Andrews, JC, Fisch, U, Valavanis, A, Aeppli, U, Makek, MS. The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach. Laryngoscope 1989;99:429–37
20 Fisch, U. The infratemporal fossa approach for nasopharyngeal tumours. Laryngoscope 1983;93:3644
21 Mickey, B, Close, LG, Schaefer, SD, Samson, D. A combined frontotemporal and lateral infratemporal fossa approach to the skull base. J Neurosurg 1988;68:678–83
22 Herman, B, Bublik, M, Ruiz, J, Younis, R. Endoscopic embolization with onyx prior to resection of JNA: a new approach. Int J Pediatr Otorhinolaryngol 2010;75:53–6
23 Mishra, A. True bilateral nasopharyngeal angiofibroma: report and review. European Archives of Oto-Rhino-Laryngology and Head & Neck 2015 [in press]
24 Banhiran, W, Casiano, RR. Endoscopic sinus surgery for benign and malignant nasal and sinus neoplasm. Curr Opin Otolaryngol Head Neck Surg 2005;13:50–4
25 Iovanescu, G, Ruja, S, Cotulbea, S. Juvenile nasopharyngeal angiofibroma: Timisoara ENT Department's experience. Int J Pediatr Otorhinolaryngol 2013;77:1186–9
26 McCombe, A, Lund, VJ, Howard, DJ. Recurrence in juvenile angiofibroma. Rhinology 1990;28:97102
27 Lloyd, G, Howard, D, Phelps, P, Cheesman, A. Juvenile angiofibroma: the lessons of 20 years of modern imaging. J Laryngol Otol 1999;113:127–34
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The Journal of Laryngology & Otology
  • ISSN: 0022-2151
  • EISSN: 1748-5460
  • URL: /core/journals/journal-of-laryngology-and-otology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed