Readers Forum 2: Recurrence of Angiofibroma

CT scan of angiofibroma recurrence in a 18 years old male. Operated twice by lateral rhinotomy approach. How to manage and prevent recurrence/residual in such a case.

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Summary of Comments
•Maxillary swing would be a good approach:... Dr Mohnish Grover

•Radiotherapy or even better gamma knife excision can be excercised.:.. Dr Shashidhar

•Extended osteoplastic maxillotomy approach is very useful:... Dr Mercy George

•Drogenil tab to shrink it. Embolise for avascular.:... Dr Devan

•Approached via maxillary swing/preauricular subtemporal approach:...Dr Rohit Verma

•REPEAT SURGERY WITH RADICAL EXCISION AFTER INITIAL EMBOLIZATION... Dr Suneel

•Lateral skull base approach...need to drill vidian canal...proposed to be region for residual tumour...: ...Dr Rajeev

•Radiotherapy does help in such cases & after 1000 rads the mass almost disappear:...Dr Prakash Moonka

•Pre op angiography & embolization.trans septal approach to gain good access.remove posterior wall of maxilla , reach pterygopalatine fossa& medial part of infratemporal fossa enblock resection of the tumour....Dr Murthy

•Since lateral rhinotomy has been done twice ( medial maxillectomy would have been a part ) follow the same approach,, will prevent another scar: ...Dr Sarvejit

•Prepare a nasal corridor first with removal of the posterior half of nasal septum , followed by a wide antrostomy, then a caldwell luc opening , all these three wil give you a wide acess to the posterior wall of maxilla.... Dr B. Karthikeyan

. radio therapy..... Dr Mahendran

.Difficult case indeed. Will need a combined infra temporal fossa and endoscopic approach to the pterygopalatine fossa...Dr V Ravi Kumar

· In such type of disease to do before surgery site of origin extension"Fisch classification" of disease and possible blood vessel origin Ist to identify before surgery: Dr. Robiul Islam

· As recurrence involves the skull base,craniofacial approach with drilling the viridian canal to prevent recurrence should be the best…….Dr Ipsit Panda

· I think the best way is inject of sclrozan matter than transpalatal approch combind with endoscopic surgery……Dr Hassan Haidar

· The midfacial degloving approach, with or without a LeFort osteotomy, improves posterior access to the tumor.We can also finish the operation with endoscopy control…..Farid Boudjenah

· Pre-op embolisation,then proceed via an infratemporal approach……Dr jayita poduval

· By FESS…..wagie

· Combined intracranial and external approach - bicoronal frontal apporach, Considering for post operative Radiotherapy if any residual disease is suspected…….Dr S.Kamala Kannan

Opinion may differ from surgeon to surgeon. some may prefer to operate via endoscopic or open approach depending upon the expertise, but preoperative embolisation is imporant and drilling of the vidian canal is a must to prevent the recurrence. The intracranial part is almost always extradural and may come out totally but if there is any residual intracranial part if any can be dealt by Gamma knife post operatively.

Dr Ravi Meher
MS(ENT), DNB(ENT), MNAMS
Associate Professor(ENT)
Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi