Original Research—Skull Base Surgery Juvenile Nasopharyngeal Angiofibroma: Does the External Approach Still Make Sense? Otolaryngology– Head and Neck Surgery 147(5) 958–963 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599812454394 http://otojournal.org Tam Cloutier, MD 1 , Yoann Pons, MD 1 , Jean-Philippe Blancal, MD 1 , Elisabeth Sauvaget, MD 1 , Romain Kania, PhD 1 , Damien Bresson, MD 2 , and Philippe Herman, PhD 1 No sponsorships or competing interests have been disclosed for this article. Abstract Objective. The aim of this study was to review recent man- agement of juvenile nasopharyngeal angiofibroma (JNA) in our institution during the past 10 years and to analyze the shift in surgical paradigm based on the rate of endoscopic approach and Radkowski staging. Study Design. Case series with chart review. Setting. The study was conducted from April 2000 to August 2010 in a tertiary care university hospital (Lariboisie `re, Paris, France). Subjects and Methods. All patients referred for a JNA were included in the study. Medical files and imaging data were retrospectively analyzed. Surgical management was then evaluated for 2 different periods (group 1, n = 31, consecu- tive patients operated on from April 2000 to June 2005, and group 2, n = 41, from July 2005 to August 2010). Results. Seventy-two patients were operated on, with a mean age of 16.25 years (range, 9-33 years). The rate of the endoscopic approach was significantly higher in group 2 than in group 1 (82.9% vs 45%). Rates of recurrence and compli- cations were similar. Recurrences (ie, residual disease grow- ing and treated by redo) were noted in 6 cases or 8.3% (group 1, n = 3; group 2, n = 3; P . .05). Conclusion. Progress in skull base anatomy, instrumentation, cameras, and surgical strategy allows for expansion of the indica- tions for endoscopic removal of JNA. This approach may have a better outcome in terms of blood loss, hospital stay, and local sequelae. Still, an external approach should be considered only for selected cases due to massive intracranial extension or optic nerve or internal carotid artery entrapment by the tumor. Keywords juvenile nasopharyngeal angiofibroma, endoscopic approach, medial maxillectomy, recurrences Received November 28, 2011; revised June 7, 2012; accepted June 20, 2012. J uvenile nasopharyngeal angiofibroma (JNA) is a benign vascular tumor, locally aggressive but rare, which devel- ops exclusively in young male patients. 1 It grows from the sphenopalatine foramen not only to the nasopharynx and nasal cavity but also to the deep spaces of the face and skull base through various anatomic foramens. Deep extensions to the skull base make surgical treatment difficult. 2 Surgical removal through the external approach used to be the cornerstone of management before the development of endoscopic surgery. Indeed, refinements in cameras, instrumentation, and navigation systems allowed endoscopic removal to be considered in some instances, with significant improvement in morbidity and mortality and better cosmetic and functional results. However, there are still some recent reports of major skull base approaches for these tumors, 3 even though recent experience has revealed that extensive cases can be managed endoscopically. 4 In an attempt to define the limits and true indications of endoscopic surgery, the aim of this study was to review recent management of JNA in our institution during the past 10 years and to analyze the shift in surgical paradigm based on the rate of the endoscopic approach and Radkowski staging. 5 Subjects and Methods Patients This study was carried out in a tertiary care university hos- pital from April 2000 to August 2010. All the patients referred for a JNA were included in the study. Medical files and imaging data were retrospectively analyzed. This study was approved by the hospital’s institutional review board. 1 Head and Neck Surgery Department, Ho ˆ pital Lariboisie `re, Paris, France 2 Neurosurgery Department, Ho ˆ pital Lariboisie `re, Paris, France This article was presented at the 2011 AAO-HNSF Annual Meeting & OTO EXPO; September 11-14, 2011; San Francisco, California. Corresponding Author: Tam Cloutier, Head and Neck Surgery Department, Ho ˆ pital Lariboisie `re, 2 rue Amboise Pare ´, 75010 Paris, France Email: tamcloutier@gmail.com