Investigation of choice for angiofibroma is?
ANSWER: (B) Contrast CTScanREF: Dhingra 5th Ed Pg 261"Contrast enhanced CT scan is the investigation of choice for both Nasopharyngeal angiofibroma and Neuroangiofibroma"NASOPHARYNGEAL FIBROMA (JUVENILE NASOPHARYNGEAL ANGIOFIBROMASIt is a rare tumour, though it is the commonest of all benign tumours of nasopharynx.Aetiology: The exact cause is unknown. As the tumour is predominantlyseen in adolescent males in the second decade of life, it is thought to be testosterone dependent.Site of Origin and Growth: The site of origin of the tumour is still a matter of dispute. Earlier it was thought to arise from the roof of nasopharynx or the anterior wall of sphenoid bone but now it is believed to arise from the posterior part of nasal cavity close to the superior margin of sphenopalatine foramen. From here the tumour grows into the nasal cavity, nasopharynx and into the pterygopalatine fossa, running behind the posterior ivall of maxillary sinus which is pushed forward as the tumour grows. Laterally.it extends into ptery go maxillary fossa and thence to infratemporal fossa and cheek.Pathology: Angiofibroma, as the name implies, is made up of vascular and fibrous tissues: the ratio of the two components may vary. Mostly, the vessels are just endothelium-lined spaces with no muscle coat. This accounts for the severe bleeding as the vessels lose the ability to contract, and also the bleeding cannot be controlled by application of adrenaline.Extensions of Nasopharyngeal Fibroma: Nasopharyngeal fibroma is a benign tumour but locally invasive and destroys the adjoining structures. It may extend into:Nasal cavity causing nasal obstruction, epistaxis and nasal dischargeParanasal sinuses: Maxillary, sphenoid and ethmoid sinuses can all be invaded.Pterygomaxillary fossa, infratemporal fossa and cheek.Orbits giving rise to proptosis and "frog-face deformity". It enters through the inferior orbital fissure and also destroys apex of the orbit. It can also enter the orbit through superior orbital fissure.Cranial cavity. Anterior cranial fossa (through ethmoid roof or cribriform plate). Middle cranial fossa is the most common. There are two routes of entry:By erosion of floor of middle cranial fossa, anterior to foramen lacerum. The tumour lies lateral to carotid artery and cavernous sinus.Through sphenoid sinus, in to the sella. Tumour lies medial to carotid artery.Clinical FeaturesAge and sex. Tumour is seen almost exclusively in males in the age group of 10-20 years.Profuse and recurrent epistaxis. This is the most common presentationProgressive nasal obstruction and denasal speech due to mass in the postnasal space.Conductive hearing loss and serous otitis media due to obstruction of eustachian tube.Mass in the nasopharynx. Tumour is sessile , lobulated or smooth and obstructs one or both choanae . It is pink or purplish in colour. Consistency is firm but digital palpation should never be done until at the time of operation.Others: Broad nasal bridge, proptosis, swelling of cheek, infratemporal fossa or involvement of 2nd. 3rd. 4th. 6th cranial nerves will depend on the extent of tumourInvestigationsSoft tissue lateral film of nasopharynx shows soft tissue mass in the nasopharynxX-rays of paranasal sinuses and base of skull may show1 displacement of nasal septum,opacification of sinuses, anterior bowing of posterior -wall of maxillary sinus, destruction of medial antral wall, erosion of greater wing of sphenoid or pterygoid plates, widening of lower lateral margin of superior orbital fissure.CT scan of the head with contrast enhancement is now the investigation of choice. It has replaced conventional radiographs. It shows the extent of tumour, bony destruction or displacements. Anterior bo\ving of the posterior wall of maxillary sinus (often called the Holman Miller or Antral sign) is pathognomicof angiofibroma. Magnetic resonance imaging (MRI) is complementary to CT scans, when soft tissue extensions are present intracranially, in the infratemporal fossa or into the orbit.Carotid angiography shows extension of tumour, its vascularity and feeding vessels. It is done whenembolisation is planned before operation.Biopsy of the tumour is attended with profuse bleeding and is therefore avoidedTreatmentSurgery: Surgical excision is now the treatment of choice. Various approaches to angiofibroma,depending on origin and extensions, are listed below.Transpalatine: For tumours confined to nasopharynxTranspalatine + Sublabial (Sardana'sapproach)Extended lateral rhinotomy (Via facial incision or Via degloving approach)Extended Denker s approachIntracranial-extracranialIntratemporal tossaEndoscopicContrast CT of Nasopharyngeal angiofibromaWhen the mass imvoives the plerygopalatine fossa, it leads to bowing of the posterior wall of the madillary antrum (Holiman Millerorintral sign; red amoars).Radiotherapy has been used as a primary mode of treatment. A dose of 3000 to 3500 cGy in 15-18 fractions is delivered in 3 -3.5 weeks.Chemotherapy. Recurrent and residual lesions have been treated by chemotherapy,doxorubicin, vincristine and dacarbazine in combination
X ray PNS
Contrast CT Scan
MRI
Carotid angiography
Tumors of Nose and PNS