Anaesthetic management of endoscopic resection of juvenile nasopharyngeal angiofibroma: our experience and a review of the literature

Background: Juvenile nasopharyngeal angiofibroma (JNA) is a rare, benign, vascular tumour in adolescent males with potential life-threatening complications. Advances in endoscopic surgery, invasive monitoring and hypotensive anaesthesia have made JNAs amenable to endoscopic surgical resection. We present the anaesthetic management of endoscopic resection of 14 JNAs, together with a review. Method: The medical records of patients who underwent endoscopic excision of JNAs within the last seven years were reviewed retrospectively. Information was collected and analysed with regard to demographics, preoperative evaluation, intraoperative management, complications and postoperative course. Fourteen patients were included in the study. If the surgery needed to be converted to open surgery, the patients were excluded from the study. Results: The age of the patients ranged from 10-18 years. Two patients had preoperative embolisation of the feeding vessel. Standard anaesthesia induction technique, together with invasive monitoring, was used. Controlled hypotension (mean arterial pressure of 60 +/- 5 mmHg) was achieved with the help of inhalational anaesthetics, vasodilators and beta blockers. Mean duration of surgery was 197.14 +/- 77 minutes, and median blood loss was 500 ml (100-4 300 ml). Seven patients were extubated in the operating room. The other seven patients remained intubated for 24 hours owing to extensive surgery with a risk of postoperative bleeding, and were monitored either in the postoperative care unit (five patients) or the intensive care unit (two patients). There was no significant morbidity or mortality in any of the patients. Conclusion: JNAs remain a challenge for anaesthesiologists because of excessive intraoperative bleeding. Anaesthetists should be aware of recent techniques to reduce tumour vascularity, such as embolisation of the feeding vessel and controlled hypotension. Invasive monitoring, together with multimodal blood conservation strategies, decreases blood loss and provides a clear field of vision for endoscopic surgery.