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  1. Definition: Locally invasive vasoformative neoplasm occurring ONLY / EXCLUSIVELY in males.
  2. Features: Triad:
    1. Recurrent epistaxis          
    2. Nasal obstruction              
    3. Nasopharyngeal mass
      1. Age group = 7-19 yrs
      2. Prepubertal to adolescent males
      3. Regression of tumours in the late teens or early twenties (reports not convincing)
      4. Tumor has no true capsule
  1. Microscopic Features:
    1. Thin-walled vascular channels lined by a single layer endothelium with or without a narrow rim and often incomplete run of smooth muscle
    2. The vessels are devoid of muscular tissue
  1. Theories of origin:
    1. Ringertz Theory: Most accepted
      Tumor arises from the periosteum of the nasopharyngeal vault
    2. Som and Neffson Theory:
      Hypertrophy of the periosteum of the skull base 
    3. Bensch and Erwing:
      From the firbocartitage of the basiocciput and basisphenoid
    4. Brunner Theory:
      Conjoined pharyngobasillar and buccopharyngeal fascia
    5. Osborn:
    6. Girgis and Fahmy;
      Cell nests of Zellballen
  1. Site of Origin:
    From the superior margin of the sphenopalatine foramen
  2. Blood supply:
    Chief blood supply: Sphenopalatine branch of internal maxillary artery
  1. Ascending Pharyngeal                         
  2. Branch of internal Carotid
  3. Vertebral                                
  4. Ethmoid
  1. Symptoms:
  1. Nasal obstruction
  2. Epistaxis (Spontaneous, profuse)
  3. Hyposmia/ anosmia
  4. Plummy voice, soft palate pushed down
  5. Otalgia/ Deafness: Eustachian tube obstruction
  6. Frog-face deformity. When tumor in the orbit cause proptosis
  7. Diplopia/ diminished vision
  8. Trismus and bulge of the parotid gland: Bulky disease in the infratemporal fossa
  9. Cranial nerve involvement: II, III, IV, V, VI
  1. Extensions:
    1. Nasal cavity Nasopharynx Pterygopalatine fossa infratemporal fossa à orbits
    2. Middle cranial fossa
    3. Anterior cranial fossa
    4. Paranasal sinuses
  1. Maxillary        
  2. Ethmoid          
  3. Sphenoid
  1. Neck: Through parapharyngeal space/sinus of morgagni
    1. Splayed nasal bones                                           
    2. Swelling in the temple &. cheek and fullness of the face investigation:
  1. Special investigations:
    1. Lateral tomography: Antral sign - Holman Miller Sign. Anterior bowing of the posterior wall of the maxillary sinus. Antral sign may not be present in 20% of the cases.
    2. C.E.C.T: Most constant features: Deformity of the base of the medial pterygoid plate (seen in the
    3. coronal cut sections) - investigation of choice. Is DiagnostiC.
      1. MRI: (gadolinium enhanced)
      2. Angiography
  2. Methods to decrease the tumor vascularity:
    1. Embolization (a day prior to surgery)
    2. Hormonal therapy (Estrogen; testosterone+ estrogen * 1 month)
      Role: For maturation of collagen
      Decrease the tumor vascularity
    3. Hypotensive anesthesia
    4. Radiotherapy (300 rads 3 wks)
      Present indications (equivocal)
      1. Tumor recurrence       
      2. Inoperable intra cranial extension
      3. Dangers:
  1. Retards facial growth
  2. Tumor induction
  3. Local changes:
  4. Atrophic rhinitis        
  5. Osteomyelitis     
  6. Soft-tissue necrosis
  1. Cryotherapy
  2. External carotid artery ligation
  3. Treatment:
    1. Surgical Excision (with or without embolization <48 hrs prior)
    2. Treatment of recurrence: surgical excision
  1. Surgical approaches to angiofibroma -
    It is selected according to tumours location. Size and effectiveness of embolization.
Approach                                                                        Indication
  1. Endoscopic trans nasal                           For nasopharyngeal nasal cavity, paranasal sinuses, pterygo palatine fossa tumours.
  2. Transpalatal approach
  3. Medial maxillectomy                                       For medial cavernous sinus medial infratemporal fossa
  4. Facial translocation (Trans facial)               
  5. Infratemporal fossa with or without                 For tumor in infratemporal fossa cavernous sinus middle cranial fossA. craniotomy

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