The LaryngoscopeLippincott Williams & Wilkins, Inc., Philadelphia© 2000 The American Laryngological,Rhinological and Otological Society, Inc.

Temporal Approach for Resection ofJuvenile Nasopharyngeal Angiofibromas

J. Dale Browne, MD; Sera L. Jacob, MD

Objective: To describe a lateral preauricular tem-poral approach for resection of juvenile nasopharyn-geal angiofibroma (JNA). Study Design: A retrospec-tive review of five patients with JNA tumors thatwere resected by a lateral preauricular temporal ap-proach. Methods: The medical records of five patientswho underwent resection of JNA tumors via a lateralpreauricular temporal approach were reviewed, andthe following data collected: tumor extent, blood loss,hospital stay, and surgical complications. Results:Five patients with JNA tumors had resection by alateral preauricular temporal approach. These tu-mors ranged from relatively limited disease to moreextensive intracranial, extradural tumors. Using thestaging system advocated by Andrews et al.,1 thesetumors included stages II, IIIa, and IIIb. Four patients(stages II, IIIa, IIIa, and IIIb) who underwent primarysurgical excision had minimal blood losses and weredischarged on the first or third postoperative daywith minimal transient complications (mild trismus,frontal branch paresis, serous effusion, and cheekhypesthesia). The remaining patient (stage IIIb) didwell after surgery, despite having undergone preop-erative radiation therapy and sustaining a significantintraoperative blood loss. There have been no perma-nent complications or tumor recurrences. Conclusions:A lateral preauricular temporal approach to thenasopharynx and infratemporal fossa provides effec-tive exposure for resection of extradural JNA tu-mors. The advantages of this approach include astraightforward route to the site of origin, the absenceof facial and palatal incisions, and avoidance of a per-manent ipsilateral conductive hearing loss. Key Words:Juvenile nasopharyngeal angiofibroma, preauricular,approach.

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INTRODUCTIONJuvenile nasopharyngeal angiofibromas (JNA tu-

mors) are highly vascular neoplasms that most commonlyarise in the head and neck region of adolescent malepatients. These benign tumors originate along the postero-lateral nasal cavity near the petroclival fissure and fromthis region of initial growth may spread extensively fol-lowing the natural soft tissue planes.1,2 When signifi-cantly advanced, these angiofibromas can result in bonedestruction and eventual intracranial extension. Althoughradiation therapy and chemotherapy have met with somesuccess in the treatment of JNA tumors, the current con-sensus for optimal treatment of these benign vascularneoplasms remains surgical resection with the former mo-dalities of therapy being reserved for unresectable dis-ease. The benign nature of these tumors, combined withthe relatively low overall recurrence rate, supports surgi-cal removal provided that resection does not result insignificant loss of form or function.

The variety of surgical approaches to JNA resectionsthat have been described in the literature provides anindication of the complexity of tumor resection in thisregion of difficult exposure and important anatomicalstructures. However different in their approach, commonto each of these methods is the straightforward goal ofmaximizing exposure and vascular control with minimalassociated morbidity. Specific considerations that are es-sential to surgical design include an accurate determina-tion of each of the following: the extent of tumor spread,the vascular supply to the tumor bed, and the ability togain secure vascular control. Advancements in skull basesurgery have helped achieve the goals of surgical resectionby improving surgical access and vascular control, therebylowering overall morbidity. Moreover, extensive JNA tu-mors of the past that were treated with primary radiother-apy would, perhaps, be initially approached surgicallytoday.

Appropriate surgical planning depends on a thoroughunderstanding of the routes of growth of these neoplasms.JNA tumors are known to initiate their growth of fibroustissue and epithelial vascular spaces in the area of fusionof the superior portion of the pterygoid process of thesphenoid bone, the horizontal portion of the posteriorvomer, and the sphenoidal process of the palatine bone.2

In this region of the pterygopalatine fossa lies the sphe-

Presented at the Meeting of the Southern Section of the AmericanLaryngological, Rhinological and Otological Society, Inc., New Orleans,Louisiana, January 15, 1999.

From the Department of Otolaryngology, Wake Forest UniversityBaptist Medical Center, Winston-Salem, North Carolina.

Editor’s Note: This Manuscript was accepted for publication April12, 2000.

Send Correspondence to J. Dale Browne, MD, Department of Oto-laryngology, Wake Forest University Baptist Medical Center, MedicalCenter Boulevard, Winston-Salem, North Carolina, 27157-1034, U.S.A.E-mail: jdbrowne@wfubmc.edu

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nopalatine, artery which is the primary initial blood sup-ply to angiofibromas. As these tumors expand, vascularsupply is increased from feeding arteries derived from theinternal carotid artery system.

Initially, the tumor growth extends along a submu-cosal plane to involve the nasopharynx, nasal cavity, andsphenoid sinus. Growth then can occur from the spheno-palatine foramen laterally into the pterygomaxillary fis-sure and eventually into the infratemporal fossa. Fromthis location, the tumor can invade the orbit via the infe-rior orbital fissure. Intracranial extension of the tumor toinvolve the anterior and middle cranial fossae is permittedby destruction of the base of the pterygoid process. Themechanism of bone destruction of these aggressive vaso-formative tumors is known to result from a pushing pat-tern of growth rather than one of infiltration. For thisreason, intracranial extension is usually extradural.1

Several surgical approaches have been used to re-move JNA tumors. For disease confined to the nasophar-ynx, nasal cavities, and ethmoid and sphenoid cavities,endonasal endoscopic, transfacial, midfacial degloving,and transpalatal approaches have been used successful-ly.3–6 For lateral extension into the maxillary sinus cav-ity, transantral exposure has been used, in addition to theaforementioned approaches.3 Tumors that extend into thepterygomaxillary space, infratemporal fossa, and orbit re-quire wider skull base exposure for safe removal. A varietyof approaches have been used to access these more exten-sive extradural JNA tumors, including 1) facial transloca-tion; 2) transpalatal, transfacial, or midfacial deglovingapproaches combined with a transzygomatic exposure;3) a lateral preauricular approach, which is combined witha frontotemporal craniotomy for intracranial disease;4) postauricular infratemporal fossa approaches that sac-rifice the middle ear space, and 5) infratemporal fossaapproaches that preserve the middle ear space.7–16

The combined transzygomatic and transpalatal exci-sion of JNA tumors can be used to remove large tumorswith limited intracranial, extradural extension.13 In thisapproach, the tumor is delivered through an extendedpalatobuccal incision. The transzygomatic exposure in-cludes a bicoronal incision, which is required to safelymobilize the superior extent of the tumor. While this ap-proach provides excellent exposure for many large JNAtumors, it is limited to those with a modest amount ofintracranial involvement, because of the limited exposureof the middle cranial fossa. The transfacial and midfacialdegloving approaches can also be combined with the tran-szygomatic approach for good exposure of most tumors.However, similar to the combined transzygomatic andtranspalatal approaches, exposure of the middle cranialfossa is limited.

The facial translocation procedure as described byJanecka et al.14 affords excellent exposure of large tumorsthrough modified Weber-Ferguson and coronal incisions.Exposure includes division and reanastomosis of the tem-poral branch of the facial nerve and sacrifice of the infraor-bital nerve. Then a frontotemporal craniotomy is per-formed. Although this approach offers excellent exposureof large JNA tumors, it is associated with facial incisions,

some degree of forehead weakness, and cheek and upperlip numbness.

The Fisch infratemporal fossa type C approach offersexcellent skull base exposure for extra-dural tumors.1,8

With this procedure, a postauricular approach is used toperform a mastoidectomy and subtotal petrosectomy. Themandibular branch of the trigeminal nerve is sectioned,and after tumor removal the middle ear structures areremoved, middle ear obliterated, and the eustachian tubeclosed. This approach allows the patient to avoid facialincisions and a craniotomy; but it results in a permanentipsilateral conductive hearing loss and chin numbness.

The combined frontotemporal and lateral infratem-poral fossa approach to the skull base as described byMickey et al.9 provides excellent exposure of the anteriorportion of the cavernous sinus and orbital apex and allowsfor the safe removal of both extradural and intraduralintracranial tumors. In this technique, the infratemporalfossa is approached laterally through a preauricular inci-sion and the zygomatic arch and lateral orbital rim aretemporarily removed. Similar in this type of exposure arethe lateral preauricular approaches reported by Gates16

and by Zhang et al.15 in their type D approaches. All threeauthors report excellent anterior exposure with the ad-vantage of preserving the integrity of the middle earspace.

Although the approach described in this report devel-oped as a modification of the Fisch infratemporal fossatype C procedure and is similar to the Fisch type D pro-cedure, the technique used in our series differs from theseand other preauricular approaches in the extent of dissec-tion necessary for exposure. This procedure is described indetail, and five illustrative cases are presented to demon-strate how this lateral preauricular approach can be usedfor all extradural stages of JNA.

CASE REPORTSFive patients have undergone JNA resection by a lateral

preauricular infratemporal fossa approach by the senior author(J.D.B.). Each case is discussed, and the specific surgical proceduredescribed.

Case 1An 11-year-old boy presented with a 4-month history of

nasal obstruction and epistaxis. Physical examination was lim-ited by turbinate hypertrophy, which did not permit visualizationof the nasopharynx. A contrasted computed tomography (CT)scan was performed, which demonstrated a mass in the area ofthe lateral nasopharynx with erosion of the pterygoid plates anda radiographic appearance consistent with a stage II angiofi-broma. The patient underwent preoperative embolization of theright-side external carotid artery feeder vessels. The followingday, the patient was taken to the operating room, where thetumor was removed through a right-side (preauricular), antero-lateral subcranial approach. The surgical findings included atumor arising from the right-side petroclival fissure with erosionof the pterygoid plates and extension into the nasopharynx with-out intracranial involvement. The total blood loss was 100 mL.Postoperatively, the patient demonstrated only mild, transienttrismus. His unilateral nasal packing was removed on the secondpostoperative day, and he was discharged to home the followingday. Follow-up CT scans at 3 and 14 months revealed completeremoval tumor.

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Case 2A 16-year-old boy presented with an 18-month history of

nasal obstruction and intermittent right epistaxis. Physical ex-amination revealed a right-side serous effusion, hyponasalspeech, and mucoid rhinorrhea with a vascular mass in his rightposterior nasal cavity. CT and magnetic resonance imaging (MRI)scans were obtained, which revealed a large enhancing massfilling the nasopharynx with extension into the maxillary, poste-rior ethmoid, and sphenoid sinuses and further intracranial/ex-tradural involvement in the area of the foramen rotundum con-sistent with a stage IIIb JNA tumor. The circulation from bothexternal carotid arteries was heavily embolized, and tumor extir-pation was performed the following day.

Intraoperatively, a large angiofibroma was found to be aris-ing from the right-side petroclival fissure with extension into theinfratemporal fossa. Bony erosion was seen around the foramenrotundum with superior displacement of the maxillary division ofthe trigeminal nerve with intracranial, extradural extension intothe middle cranial fossa. The tumor was removed through ananterolateral preauricular subcranial approach, as describedlater. This approach allowed dissection of the tumor from thesecond division of the trigeminal nerve (V2) and the adjacentdura. The patient remained hemodynamically stable during theprocedure, sustaining a total blood loss of 200 mL. After surgery,he demonstrated mild, transient paresis of the frontal branch ofthe facial nerve, hypesthesia of V2, and mild trismus. On postop-erative day 2 his nasal pack was removed without bleeding, andthe patient was discharged to home on postoperative day 3. Sixmonths after surgery, the patient’s serous effusion and motor(forehead branch of facial nerve) and sensory (V2) deficits hadcompletely resolved. Two years after surgery, the patient re-mained free of disease.

Case 3A 9-year-old boy presented with a 9-month history of nasal

congestion and a 3-week history of left-side frontal headaches andleft-side proptosis.10 An infused CT scan was performed, whichrevealed a large mass with radiographic imaging consistent withJNA. The mass was invading the left-side infratemporal fossawith extension into the sphenoid sinus and destruction of thesella turcica with upward displacement of the cavernous portionof the left internal carotid artery (stage IIIb). Because of thepatient’s age and the extensive nature of his disease, the childunderwent 3454 cGy of radiation therapy via linear accelerator.This measure resulted in a significant decrease in the tumor sizeand a resolution of his symptoms. The mass remained stable overthe next 3.5 years, as was documented by serial MRI scans. Afterthis time, however, the patient began complaining of increasingnasal obstruction. An MRI scan revealed the tumor to have in-creased by approximately 20% with continued extension into theright-side nasal cavity and sphenoid sinus. There was continuedextension of disease into the region of the cavernous sinus andbase of the middle cranial fossa with elevation of the temporallobe (Fig. 1).

At 13 years of age, the patient was referred to the seniorauthor for resection and subsequently prepared for definitiveextirpation by preoperative embolization. However, multiplelarge bilateral cavernous carotid artery feeders (greater on theipsilateral side) could not be embolized. Although the potentialconsequence of significant intraoperative blood loss was appreci-ated, preoperative permanent balloon occlusion of the larger ip-silateral internal carotid artery was not performed, because of theyoung age of the patient. The following day, the tumor wasremoved via the lateral preauricular temporal fossa and midfa-cial degloving approaches. The tumor was found to occupy theentire nasopharynx with bone erosion over the left-side orbital

apex, left cavernous sinus, and adjacent sphenoid bone, withsome extension and deformity of the contralateral pterygomaxil-lary fossa. Further, because of prior irradiation, the tumor wasfound to be densely adherent to the middle fossa and cavernoussinus dura, as well as the contralateral posterolateral nasal walland nasopharynx. Although a plane of dissection was ultimatelydefined, intense bleeding was encountered in the area of thepetrous carotid, and the wound had to be packed repeatedly andintermittently, according to the rate of hemorrhage and hemody-namic stability of the patient. Total blood loss during the 12-hourprocedure was estimated at 10,000 mL; blood products were re-placed throughout the surgery to maintain stable cardiopulmo-nary function. No intradural extension was present, and ulti-mately, the tumor was removed, leaving the wide dural interfaceintact.

The patient’s postoperative course was uneventful. He wasreturned to the operating room on postoperative day 6 for nasalpack removal. No bleeding was encountered, and the patient wasdischarged to home the following day. The child initially experi-enced mild trismus, which resolved over the following 2 months.The frontal branch of his facial nerve has remained intact withoutever demonstrating weakness. Seven years after surgery, he wasan active college student without sequelae from his extensiveblood product replacements. His 5-year postoperative CT scanrevealed no evidence of recurrence (Fig. 2). The only reminder ofhis surgery is the mild concavity of the left temporal region. Hispreauricular scar is unnoticeable, and his hair covers the tempo-ral scalp scar.

Case 4A 21-year-old man presented with a 2-year history of right-

side nasal obstruction that was unresponsive to medical manage-ment. Nasal endoscopy revealed a vascular mass obstructing theright posterior nasal cavity. A CT scan revealed findings con-sistent with a JNA stage IIIa tumor. The patient underwent

Fig. 1. Preoperative infused magnetic resonance imaging (MRI) ofpatient 3 demonstrating a large juvenile nasopharyngeal angiofi-broma (JNA) that has displaced the left-side cavernous sinus andelevated the temporal lobe.

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preoperative embolization followed by surgical removal the sameday. Intraoperatively, the tumor was found to erode the right-sidelateral and medial pterygoid plates with extension into the infra-temporal fossa and intimate association with V2. The tumor wasapproached by the lateral subcranial method leaving V2 and theposterior orbital floor intact (Figs. 3–9). The surgical procedurewas accomplished with a total blood loss of 250 mL. The patientwas observed overnight and discharged the following day, afternasal pack removal. After surgery he experienced moderate tris-mus and hypesthesia of V2. The trismus quickly resolved, and thepatient was tolerating a normal diet by the second postoperativeweek. Cheek sensation had completely returned to normal by thesixth postoperative week. One year after surgery the patientremained free of disease.

Case 5As an 8-year-old boy, the patient initially underwent resec-

tion of a stage II JNA tumor via a midfacial degloving procedure,followed by endoscopic removal of a 1.5-cm residual mass withinthe sphenoid sinus 9 months later. Yearly MRI scans obtainedthrough his local physician revealed no evidence of recurrentdisease until 12 years of age, when he presented with a 3-monthhistory of progressive nasal obstruction. CT and MRI studiesrevealed a recurrent stage IIIA JNA tumor filling the nasophar-

ynx and eroding bone at the skull base around foramen rotun-dum. Review of prior studies suggested that the recurrence arosefrom tumor that was not appreciated within the ipsilateral ptery-goid plates at the initial anteriorly oriented resection. The patientwas subsequently referred for surgical therapy and underwentpreoperative embolization of multiple bilateral external carotidfeeders. Several ipsilateral petrous and cavernous carotid feederscould not be embolized.

Via a preauricular temporal approach, the tumor was re-moved in total, with an estimated blood loss of 800 mL. Briskbleeding was encountered during dissection of the tumor awayfrom the skull base and the adjacent exposed and elevated V2

trunk underneath the temporal horn. Unlike the irradiated tu-mor in patient 3, the lesion was expeditiously dissected to mini-mize blood loss from the internal carotid feeders. No replacementblood products were necessary. An ipsilateral nasal tampon packplaced at the conclusion of the procedure was removed on the firstpostoperative day; the patient was discharged on the secondpostoperative day. Six months after surgery there was no evi-dence of recurrent disease; postoperative trismus was mild andtransient and infraorbital nerve function was normal, despitedisplacement by the tumor requiring nerve retraction and eleva-tion during tumor removal.

MATERIALS AND METHODS

Surgical MethodThe patient is positioned in the supine position and placed

under general anesthesia, and oral intubation is established. Thehead is rotated to the contralateral side, and the temporal regionshaved and prepped with Betadine. Hemostasis is aided by theinjection of 1% lidocaine with a 1:100,000 concentration of epi-nephrine along the planned line of incision. A curvilinear preau-ricular incision beginning in the pretragal area and curving in aC-shaped fashion into the temporal fossa is performed (Fig. 4).Sharp dissection is used to elevate the anterior skin flap to thezygomatic arch. Care is taken to avoid injury to the frontal branchof the facial nerve by elevating it with the surrounding soft tissueand periosteum overlying the zygoma (Fig. 5). A microplate ispredrilled in the area of the zygomatic arch and the lateral orbitalrim in preparation for replacement of this segment of bone at theconclusion of the procedure. The zygomatic arch is removed at itsjunction with the lateral orbital rim and glenoid fossa; inferiordisplacement of the zygoma is unnecessary. The temporomandib-ular joint is left untouched and the parotid is not dissected. After

Fig. 2. Five-year postoperative infused computed tomography (CT)scan of patient 3 demonstrates the surgical defect and line ofsurgical access (thin arrow).

Fig. 3. Transverse CT of patient 4. Star 5 stage IIIa JNA. Fig. 4. The curvilinear preauricular incision used in patient 4.

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removal of the zygomatic arch, electrocautery is used to performa subperiosteal elevation of the temporalis muscle from the lat-eral orbital wall, squamosa of the temporal bone, and the lateralprocess of the sphenoid, with the muscle pedicled inferiorly on thecoronoid process of the mandible. This results in exposure of thebone over the orbital apex and temporal horn, the lateral bone ofthe greater wing of the sphenoid bone, and the squamosa portionof the temporal bone (Fig. 10).

The extent of bone removal depends on the extent of tumorwith varying portions of the lateral orbital wall, orbital apex, andcontiguous bone of the greater wing of the sphenoid bone removeddown to the middle fossa dura and periorbita as necessary. Fortumors that either directly contact dura or significantly involveV2 on preoperative scanning, a small skull base temporal crani-ectomy overlying the temporal horn is performed with a high-speed drill to allow the temporal lobe dura to be retracted awayfrom tumor and involved trigeminal nerve branches. By gentleelevation of the middle fossa dura, the bone underlying the tem-poral horn can be sequentially removed up toward the cavernoussinus and petrous carotid, if necessary. Smaller tumors that donot impact V2 or contact dura do not necessarily require duralexposure during the dissection. The lateral pterygoid muscle ismobilized anteriorly and laterally, allowing for improved expo-sure. As mentioned, the temporomandibular joint and parotid areleft undisturbed in this approach.

After this initial exposure, the superior portion of the me-dial and lateral pterygoid plates are removed by drilling away theremaining sphenoid bone, with the extent of bone removal, again,dictated by tumor extent. The tumor is identified at or just deepto the pterygoid plates. The maxillary division of the trigeminalnerve is identified in the inferior/lateral orbital wall dissection asbone is sequentially removed for tumor exposure; this approachallows for protection and separation of V2 from tumor underdirect visualization. In larger tumors, V2 is frequently dehiscentand displaced superiorly by the JNA. It can be identified lying onthe surface of the tumor as it is approached laterally (Fig. 6).

The Fisch infratemporal fossa retractor is placed for im-proved exposure of the tumor. When necessary, the mandibulardivision of the trigeminal nerve is identified and preserved. Bluntdissection is used to mobilize and sweep the tumor toward theattachments at the lateral nasopharynx, taking care to avoidinjury to any adjacent dura, periorbita, or trigeminal nervebranch. A sharp tenaculum is used to firmly grasp and pull the

tumor out through the lateral defect while dissection continueswith blunt elevators through the defect (Figs. 7 and 8). To rou-tinely avoid extensive blood loss during this portion of the proce-dure, adequate preoperative embolization is essential. Intracra-nial, extradural disease can be removed using this approach. Ifpreoperative imaging studies suggest extensive intradural exten-sion, a pterional craniotomy can be performed through the expo-sure to allow direct visualization and removal of the tumor.

After tumor removal, bleeding is controlled by temporarygauze packing and bipolar cautery. As a dressing, the ipsilateralnasal cavity is filled with nasal tampon packing preceded bylining the operative cavity lined with thrombin-soaked Gelfoam.Approximately half of the temporalis muscle is left pedicled pos-teriorly and secured against the lateral orbit to fill the temporalfossa and therefore minimize the postoperative depression inthis area. The remaining anterior half of the muscle is reservedfor rotation into the infratemporal fossa cavity to provide softtissue bulk in the cavity and as a barrier between the nasalcavity/nasopharynx and dura. Then the zygomatic arch is secured

Fig. 5. Exposure of zygomatic arch, lateral orbital rim, and tempo-ralis muscle in patient 4, after elevation of the skin flap with perios-teum overlying the zygomatic arch and lateral orbital rim.

Fig. 6. Tumor exposure through the preauricular lateral approach.White arrow points to trigeminal nerve (V2) after removal of bone attemporal horn and lateral orbit; black arrow points to the tumordisplacing V2.

Fig. 7. The tumor is pulled out through lateral defect made intonasopharynx via the lateral approach using tenaculums.

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into its original position with titanium miniplates. The scalpincision is closed. A suction drain is placed.

This procedure alone was employed for tumor extirpationfor patients 1, 2, 4, and 5. In the case of patient 3, this lateralpreauricular approach was combined with a midfacial deglovingapproach for tumor exposure. Although unnecessary in this se-ries, the preauricular curvilinear temporal incision allows accessfor expansion of the exposure to include the anterior middle earspace for carotid dissection and exposure, and/or a pterional cra-niotomy for extensive intradural exposure of tumor and cavern-ous carotid access.

DISCUSSIONThe evolution and refinements made in skull base

surgery, anesthesia, and endovascular neuroradiology

have, undoubtedly, expanded the limits of resectability ofcomplex lesions such as JNA tumors. The number andvariety of reported techniques attest to the challenges ofsurgical therapy in this region. Regardless of the route oftumor access, each approach has sought to maximize ex-posure while limiting morbidity. With these same goals, alateral preauricular approach was used in this series toexpose the anatomical region of tumor origin at the begin-ning of the dissection and allow direct exposure of thecranial base involved with tumor extension. The potentialhazard of leaving behind a nidus of tumor within air cellsin and around the pterygoid plates (as seen in patient 5) isminimized by the lateral approach, which allows directexposure of this area.

The fibrous nature of an embolized JNA allows thistumor to be literally pulled laterally from the nasophar-ynx via the surgical entry zone, once critical attachmentshave been severed by drilling, and blunt or sharp dissec-tion (e.g., pterygoid plates, dural adhesions, envelopmentof V2, nasopharyngeal mucosa, and pterygoid muscula-ture). Limiting bone removal and exposure to that re-quired for tumor exposure allows flexibility in this ap-proach and its applicability to a wide variation in tumorextent. The preauricular placement of the incision inclu-sive of the temporal fossa allows potential expansion ofexposure via a pterional craniotomy for extensive intra-dural disease.

The minimal morbidity encountered through thispreauricular approach is attributable in part to confiningthe major surgical approach to a lateral one. In a purelateral approach, there are no palatal, sublabial, or trans-facial incisions; an oral diet is hampered only by mildtransient trismus. The nasal packing is only ipsilateral.The middle ear is unharmed, and the eustachian tube isdissected from the tumor with the other muscular andmucosal attachments. For this approach to be used, excel-lent preoperative embolization of all external carotid feed-ers is essential. With the exception of the preoperativelyirradiated patient 3 with a stage IIIb tumor, no patientsrequired blood replacement.

Although not exclusively employing a lateral ap-proach, the therapy of patient 3 was included in this small

Fig. 8. Defect created after tumor removal. Star 5 lateral orbit;arrow 5 V2; triangle 5 temporalis muscle.

Fig. 9. Postoperative transverse CT scan of patient 4. Star high-lights the temporalis muscle flap inserted into the defect created bytumor removal.

Fig. 10. Illustration of exposure achieved by the lateral approach.

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series to illustrate the benefit of complementing the lat-eral approach with an anterior midfacial degloving proce-dure in very extensive intracranial, extradural lesionsinvolving bilateral nasal walls. Although understandableat the time, it is unfortunate that patient 3 received irra-diation, because this led to intense fibrosis at an extensivedural/tumor interface. In this setting of wide dural in-volvement and multiple bilateral petrous/cavernous ca-rotid feeders remaining after embolization, extensiveblood loss was anticipated and experienced. Hemorrhagewas significant; nevertheless, this approach allowed care-ful dissection in a fibrotic surgical field. Separation oftumor from dura was accomplished without a cerebrospi-nal fluid leak or intracranial complications. Although thislateral approach was beneficial to patient safety, bloodloss and surgical time would have been less in a nonirra-diated field. Efforts at developing the use of percutaneous,direct puncture therapeutic embolization of vascular neo-plasms can significantly complement the care of patientswith large JNA tumor with persistent internal carotidfeeders following traditional endovascular procedures.17

CONCLUSIONAs described, this reports summarizes the successful

application of a lateral preauricular infratemporal fossaapproach to the nasopharynx and skull base to removeJNA tumors ranging in size from small, isolated disease toextensive intracranial, extradural tumors. Unlike priorreports of preauricular and lateral techniques, this seriesreports a technique involving minimal bone removal thatis dictated by tumor extent and involves only the removalof bone away from tumor and dura that is necessary forsafe extirpation. The temporomandibular joint, parotid,zygoma, facial nerve, and trigeminal nerve branches areleft undisturbed; only the zygomatic arch is temporarilyremoved. In each case, the approach was well toleratedwith minimal morbidity and excellent exposure at theaffected skull base. In the four nonirradiated patients inthis series, the procedure was combined with preoperativeembolization, resulting in minimal blood losses and shorthospital stays. Cosmetic deformities are limited to well-hidden scalp and preauricular scars, since all facial inci-sions are avoided. The temporal fossa depression is mini-mal and generally covered by hair. The use of this lateralpreauricular approach allows flexibility in the degree ofbone removal and dural exposure to achieve visualizationof the nasopharynx and infratemporal fossa for the safeand complete removal of these tumors. Limiting exposureto this lateral technique minimizes the morbidity encoun-tered with transoral, transmaxillary, or transnasal proce-dures. When used in conjunction with effective endovas-cular embolization of the tumor, excision of angiofibromasis straightforward and affords visualization of the tumor

base at the beginning of the dissection. This techniqueshould be considered as a preferential (although not ex-clusive) approach in the resection of all angiofibromas,without limiting its application to only large tumors.

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