34 Angiofibromas and Other Vascular Tumors of the Skull Base

Soma Subramaniam and Ricardo L. Carrau


Vascular tumors are a relatively rare entity in head and neck neoplasms. Angiofibromas account for most of these tumors. A summary of current staging systems is given. Management of angiofibroma is primarily endoscopic endonasal surgical resection, with preoperative embolization in most cases. The endonasal endoscopic transpterygoid approach is a useful technique in this scenario. The role of hormonal and targeted therapy is currently mainly adjuvant and requires further evaluation. A brief discussion of other vascular tumors is also provided.

34 Angiofibromas and Other Vascular Tumors of the Skull Base

34.1 Introduction

Vascular tumors of the skull base, primarily angiofibromas, pose a significant surgical challenge because of their anatomical position, potential for expansion and bony destruction, and potential for significant perioperative bleeding. Methodical and systematic planning, exercising of sound surgical principles and technique, and provision of comprehensive perioperative care can help in surmounting these drawbacks. Angiofibroma is the most commonly encountered vascular tumor in this region. “Juvenile nasopharyngeal angiofibroma”1 should be considered a misnomer, as it neither exclusively occurs in the juvenile age group nor truly arises from the nasopharynx.

The gross tumor specimen appearance can range from small and smooth to large and multilobulated, with color anywhere from light tan to reddish/purple. Erosions and ulcerations can be commonly seen on the surface of this tumor, if large. Histologically, it consists of two components: fibrous stroma and vascular spaces. The fibrous stroma is composed of spindle-shaped cells in a dense collagen matrix. Within this dense matrix is a vast network of irregular vascular channels of variable size. These endothelial-lined spaces lack the surrounding smooth muscle that is normally seen in blood vessels, which is the likely cause for the significant hemorrhage that occurs following manipulation.

The most common presentation of a sinonasal angiofibroma includes painless nasal obstruction, recurrent unilateral epistaxis, and a sinonasal or nasopharyngeal mass. The epicenter of the tumor origin is the lateral basisphenoid, between the sphenoid sinus and pterygopalatine fossa, in the region of the sphenopalatine foramen.2 ,​ 3 From its site of origin, it expands and erodes surrounding bone, taking the path of least resistance. It preferentially follows preformed pathways, medially to the nasal cavity, nasopharynx, and sphenoid sinus; laterally to the pterygopalatine fossa, gaining further access to the infratemporal fossa, as well as to the orbit via the inferior orbital fissure; anteromedially into the maxillary and ethmoid sinus; and posteriorly/superiorly along the foramina of the vidian canal and foramen rotundum toward middle cranial fossa. Direct extension intracranially is also possible, eroding through the cribriform plate, fovea ethmoidalis, and planum sphenoidale.4

Other vascular tumors of the head and neck region include hemangioma, tufted angioma, glomangiopericytoma, angiosarcoma, and vascular polyps. Hemangioma, which usually presents in the infantile period, primarily affects the upper airway (subglottis of larynx), sinonasal tract, and nasal dorsum and has not been reported to originate in the skull base region. Similarly, tufted angioma and acquired lobular capillary hemangioma (pyogenic granuloma) affect primarily the cutaneous regions and anterior nasal cavity and do not generally originate in the skull base. Later in this chapter, we describe glomangiopericytoma (a distinct form of hemangiopericytoma) and angiosarcoma, two entities that have a predilection for the skull base.

34.2 Incidence and Epidemiology

Angiofibroma is a rare tumor, accounting for less than 0.5% of all head and neck neoplasms. A national study from Denmark noted an incidence per year of 3.7 cases per million males aged 10 to 24 years between 1981 and 2003.5 It occurs mostly in adolescent males aged between 11 and young adulthood, although there have been reports of cases ranging from 6 years to 43 years, confirmed by histology.6 In a recent systematic review, the mean age of presentation was 17.2 years.7 There have been reports of this disease occurring in women, but these are rare instances and probably represent misreporting of other types of fibrovascular tumors rather than true angiofibromas. The data seem skewed toward larger case series from more populous countries, such as India and China, but the evidence does not suggest that angiofibroma exclusively involves any one ethnic group.8

34.3 Pathology

34.3.1 Angiofibroma

The pathological classification and etiology of angiofibromas have historically been points of disagreement and confusion among researchers owing to their relative rarity and unique morphology, as well as uncertainty about their etiology. Histologically, they consist of abundant fibroblastic stroma within which are embedded vascular channels of various sizes, ranging from capillaries to sinuses.9 Clinically, angiofibromas exhibit locally aggressive characteristics. Angiofibroma has been variously described as hemangioma, vascular malformation,10 hyperplastic lesion in response to inflammatory or allergic stimulus, excessive growth of paraganglionic tissue,11 hamartoma,12 and even extracolonic manifestation of familial adenomatous polyposis.13 However, controversy remains over whether angiofibroma represents a hemangioma/vascular tumor or a vascular malformation.

As far back as 1982, Glowacki and Mulliken14 published a histology-based classification of vascular lesions, essentially dividing this vast group of conditions into two groups—hemangiomas or vascular malformations. The key differentiating factor was histological evidence of increased mitotic activity and endothelial proliferation resulting in hyperplasia in the former, but no such proliferative activity, with normal mitotic activity, in the latter. In the modern era of immunohistochemical techniques for differentiating cell lines, the ability to detect proliferative markers with the aid of monoclonal antibodies has helped clarify this matter.

In vascular lesions, such as angiofibroma, markers for angiogenic stimulation would be the best indicators of vascular proliferation. These include VEGF (vascular endothelial growth factor), VEGFR or Flt-1/Flk-1 (vascular endothelial growth factor receptor), and CD34 antigen, as well as other associated proliferative indicators, such as FGF (fibroblast growth factor) and PCNA (proliferating cell nuclear antigen).15 Multiple studies have confirmed that VEGF is the most prominent proangiogenic marker of this group.16 ,​ 17

In 1994, Takahashi and colleagues found that FGF and VEGF protein levels were elevated in hemangiomas. By contrast, vascular malformations did not express bFGF and VEGF.18 In 2006, Saylam and colleagues analyzed the VEGF immunoreactivity of 27 angiofibroma samples and concluded that Juvenile nasopharyngeal angiofibroma (JNA) was a vascular and proliferative tumor.19 More recently, Zhang and colleagues20 identified immunoreactivity of CD34 in both JNA and OCH (orbital cavernous hemangioma, also a misnomer, as histologically it has been better characterized as a vascular malformation). However, the CD34 immunostaining was significantly higher in JNA than in OCH. Such findings support the view that JNA has a characteristic of vasoproliferative activity, more consistent with a vascular tumor than with vascular malformation.

Another area of dispute is whether the neoplastic component of the tumor arises from the vascular component or from the fibroblastic stroma. Proponents of the vascular component theory suggest that incomplete regression of the first branchial arch artery results in the persistence of a residual vascular network in the region of the sphenopalatine foramen, which under the influence of hormonal surges in the periadolescent period results in tumor growth.21 However, immunohistochemical studies have not consistently confirmed the relationship of positive hormone receptor status (e.g., androgen, estrogen, progesterone) within these tumors.19 ,​ 22 ,​ 23 Conversely, increasing evidence suggests that the fibroblastic stroma is instead the focus of the neoplastic transformation. This is suggested by the immunohistochemical localization of beta-catenin only to the nuclei of stromal cells rather than to endothelial cells.24

Of interest, angiofibromas have been reported to occur up to 25 times more frequently among patients who have familial adenomatous polyposis. This finding suggests that alterations of the adenomatous polyposis coli (APC)/beta-catenin pathway may be involved in the pathogenesis of angiofibroma.13 ,​ 25

34.3.2 Other Vascular Tumors


Glomangiopericytoma (GPC), previously categorized as a sinonasal variant of hemangiopericytoma, is now considered a distinct tumor type under the 2005 World Health Organization classification of head and neck tumors.26 The unencapsulated tumor is present beneath an intact respiratory epithelium, unless it has eroded through. The characteristic appearance is that of a “patternless” diffuse architecture, which may efface or surround normal tissue. The pattern of arrangement of the cells includes short fascicles, reticular pattern, or short palisades of closely packed cells. These cells are separated by a rich vasculature ranging from capillaries to large patulous spaces, giving the characteristic “staghorn” or “antlerlike” configuration. Other features include low mitotic activity (< 3/hpf), with absent to mild nuclear pleomorphism, mast cells, eosinophils, and extravasated erythrocytes. Necrosis and atypical mitoses are typically absent.27

The immunohistochemistry profile of GPCs includes reactivity with smooth muscle actin (SMA), nuclear b-catenin, cyclin-D, vimentin, and factor XIIIA (strong and diffuse reaction for the first of these three). It lacks expression of CD34, CD31, FVIII-R Ag, CD117, STAT6, bcl-2, AE1/AE3, CK7, EMA, desmin, S100 protein, GFAP, CD68, CD99, and NSE.

GPCs are a rare entity, accounting for less than 0.5% of all tumors in the sinonasal and skull region.28 Several hundred cases have been reported in the literature, the majority of which have arisen within the nasal cavity and inferior/middle turbinates. The sinuses and skull base/intracranial extension have been involved less frequently. In an Armed Forces Institute of Pathology (AFIP) review of 104 GPC tumors, age at presentation was 5 to 86 years, with a mean of 62 years and approximate equal distribution of males/females.28 Presenting symptoms include nasal obstruction and epistaxis, as well as rhinorrhea, facial pain, and infraorbital region numbness. Gross tumor appearance is polypoid, nontranslucent, beefy red to grayish pink, soft, edematous, and fleshy to friable in texture.

Treatment of GPCs is primarily surgery, even in the case of recurrences. Large case series have alluded to excellent 5-year survival of 90%29 ,​ 30 when complete surgical resection of the tumor has been achieved. Radiation treatment is generally reserved for unresectable disease.


Angiosarcoma is a rare, high-grade malignant vascular tumor that accounts for less than 0.1% of all sinonasal malignancies and for 2% of all sarcoma.31 In 10 cases of sinonasal tract angiosarcomas from AFIP, with age ranging from 13 to 81 years and almost equal male/female involvement, 8 arose from the nasal cavity and 2 from the maxillary sinus. The gross appearance of the tumor is vascular, generally purple to red, soft and friable, and it is often ulcerated with associated hemorrhage and necrosis. Microscopy reveals anastomosing vascular channels that appear tortuous and irregular, with small to large cavernous spaces. The endothelial cells are atypical, exhibiting pleomorphic nuclei with irregular nuclear contours and mitotic figures. Immunohistochemistry is characterized by immunoreactivity with Factor VIII-RA, CD34, CD31, and SMA but is nonreactive with keratin and S-100 protein. Ki67 is usually reactive (> 10%).32

Clinical presentation includes epistaxis, nasal obstruction, and nasal discharge. Treatment involves surgical resection, with possible adjuvant radiation and chemotherapy. Local recurrence following surgical resection occurs in more than 50% of cases and is the most common pattern of treatment failure. The majority of recurrences become apparent within 2 years of initial treatment. Regional metastases are less common, occurring in less than 20% of cases in most large series. Cervical lymph node metastases are more common in lesions arising from the scalp, and regional lymph node dissection is recommended in patients who have scalp lesions or palpable lymphadenopathy. Distant metastases occur in 30 to 50% of cases, with the lungs and liver most frequently involved. The overall 5-year survival for sinonasal angiosarcoma is generally poor, ranging from 12 to 33%.33

Traditional chemotherapy regimens have not been established but have included a combination of ifosfamide, paclitaxel, and doxorubicin for soft tissue sarcomas.34 Bevacizumab, a humanized monoclonal antibody against VEGF, has shown some promise in helping to control inoperable cases of angiosarcomas of the head and neck in a few case reports.

34.4 Staging

For angiofibroma, imaging studies play a determining role in its diagnosis and staging. The anatomical detail that can be obtained from modern imaging has obviated the need to biopsy these lesions, thereby avoiding serious or catastrophic bleeding in the office. Biopsies are usually sent from the operating room after embolization. A combination of CT (provides bony anatomical detail) with MRI (provides good soft tissue detail, differentiates tumor from secretions, and is particularly useful for suspected orbital or intracranial extension) ascertains the extent of tumor spread.

Historically, several staging systems have been described for angiofibromas. The Andrews35 and Radkowski36 systems (largely based on the Sessions37 system described 15 years earlier) have been the most widely used, as evidenced in a systematic review on this subject.7 Other systems have been described, including the Fisch,38 Chandler,39 and Onerci40 systems. Earlier systems did not consider the radiological features of modern imaging techniques and so have limited use. More recently, Snyderman and colleagues published the UPMC (University of Pittsburgh Medical Center) staging system.41 This system considers the presence or absence of residual vascularity after embolization, indicating the possible recruitment of vessels beyond the internal maxillary artery, including the internal carotid artery or bilateral blood supply. In general, we prefer the Andrews and UPMC systems to stage angiofibroma. A summary of these staging systems is offered in Table 34.1.

Table 34.1 Angiofibroma staging systems

Sessions 1981

Chandler 1984

Andrews 1989

Radkowski 1996

Onerci 2006

Snyderman 2010

Stage I

1a Limited to nose and NP 1b Extension into 1 or more sinuses

Limited to NP

Limited to NP, bone destruction negligible or limited to PPF

= Sessions

Nose, NP, ethmoid and sphenoid sinuses or minimal extension into PPF

Nasal cavity, medial PPF

Stage II

2a Minimal extension into PPF

2b Full occupation of PPF with or without erosion of orbit

2c ITF with or without cheek extension

Extension into nasal cavity or sphenoid sinus

Invading PPF or maxillary, ethmoid, or sphenoid sinus with bone destruction

= Sessions (IIC posterior to pterygoid plates)

Maxillary sinus, full occupation of PPF, extension to anterior cranial fossa, limited extension into ITF

Paranasal sinuses, lateral PPF; no residual vascularity

Stage III

IC extension

Tumor into antrum, ethmoid sinus, PPF, ITF, orbit, and/or cheek

Invading ITF/orbit
IIIa No IC involvement

IIIb With IC extradural (parasellar) involvement

Erosion of skull base:

IIIa Minimal intracranial extension

IIIb Extensive IC extension with/without cavernous sinus

Deep extension into cancellous bone at pterygoid base or body and GW sphenoid, significant lateral extension into ITF or pterygoid plates, orbital, cavernous sinus obliteration

Skull base erosion, orbit, ITF; no residual vascularity

Stage IV


IC extension

Intracranial, intradural tumor

IVa Without cavernous sinus, pituitary, or optic chiasm infiltration

IVb With cavernous sinus, pituitary, or optic chiasm infiltration


IC extension between pituitary gland and ICA, tumor localization lateral to ICA, middle fossa extension, and extensive IC extension

IV: Skull base erosion, orbit, ITF; residual vascularity V: IC extension, residual vascularity (M: medial extension, L: lateral extension)

Abbreviations: GW, greater wing; IC, intracranial; ITF, infratemporal fossa; NP, nasopharynx; PPF, pterygopalatine fossa.

Staging for angiosarcoma does not follow the American Joint Committee on Cancer (AJCC) system, which is applied to other soft tissue sarcomas. At present, there is no accepted staging for sinonasal angiosarcoma, although lymph node and distant metastasis is not common at initial presentation. Similarly, although a grading system of grades I through III is used in soft tissue angiosarcoma, this system has not been applied to sinonasal angiosarcoma. Grading has not yet been proven to have a clinical prognostic significance in sinonasal tract angiosarcomas, although further evaluation with a larger number of cases has been suggested.42

34.5 Treatment

34.5.1 Surgery

The mainstay treatment of angiofibromas and most other vascular tumors is surgery, but age, symptoms, and expected prognosis also influence the decision, especially for benign tumors. Surgical approaches for angiofibroma resection can be broadly classified into external and endonasal endoscopic approaches. External approaches may follow an anterior route, via midfacial degloving/endonasal, transantral, Denker’s approach, or LeFort I or via Weber-Ferguson type incision, or a lateral route, via an infratemporal approach,43 with or without a craniotomy (for cases of significant intracranial invasion). Inferior transpalatal approaches have also been described but have mostly fallen into disuse. Small tumors may be exposed and removed by removing the ipsilateral hard palate after raising the mucoperiosteum in a U-shaped fashion; however, these tumors are amenable to an endoscopic resection, which is associated with fewer sequelae and complications. Removal via transpalatal approaches that divide the soft palate were abandoned due to poor visualization of the tumor, association with significant blood loss, and negative effect on speech quality secondary to soft palate fibrosis and scarring. To determine the best surgical approach, one must consider multiple factors related to tumor (stage), patient, and surgeon/institution.

The endonasal endoscopic approach has become the preferred option to resect these tumors today in view of the better visualization, lower morbidity, lack of external scars, and lower level of blood loss. Nonetheless, although many of these tumors can in principle be resected via an endonasal endoscopic approach, whether they can be in practice depends on the level of expertise and resources available at a given institution. Most authors agree that patients whose tumors correspond with up to Andrews stage IIIa are candidates for an endoscopic endonasal approach. However, endoscopic approaches have also been described for resecting stage IIIb tumors (intracranial, extradural extension).44 Table 34.2 summarizes the literature regarding endoscopic removal of angiofibromas over the past 15 years, analyzing the stage of tumor resected, rates of persistent/recurrent disease, and operative blood loss. Excluded from analysis were case series involving fewer than 10 patients, those in which tumor stage was not provided, and those involving inadequate or absent follow-up data.

Table 34.2 Endoscopic endonasal approach outcomes for sinonasal angiofibroma

Publication (year)


Staging system

Tumor stage

Mean follow-up (range, months)

Recurrent/residual disease


Blood loss (mean)

Jorrisen (2000)a


Radkowski/ Chandler/ Andrews/ Sessions

4 stage IA–IB
4 stage IIA–IIB
4 stage IIC
1 stage IIIA

35.3 (12–72)

1 for stage IIC after 6 mo (7.7%)
1 for stage IIIA after 4 mo (7.7%)



Roger (2002)b



4 stage I
7 stage II
9 stage IIIA


2 for stage IIIA (10%)



Onerci (2003)c



8 stage IIC
4 stage III


2 for stage IIIA (16.7%)



Nicolai (2003)d



2 stage I
9 stage II
3 stage IIIA
1 stage IIIB

50 (24–93)

1 (6.7%)



Hofmann (2005)e



1 stage I
15 stage II
5 stage IIIa

51.7 (5–120)

3 (14.3%)



Borghei (2006)f



14 stage IA-IB
9 stage IIA-IIB

33.1 (14–57)

1 for stage IIB (4.3%)

3 (synechiae)

450–1,600 (881)

Andrade (2007)g



8 stage I
4 stage II

35 (12–60)




Gupta (2008)h



6 stage I
20 stage IIA–IIB
2 stage IIC


1 (stage IIC)

1 intraop IMA bleed

168/360 (with/without preop embolization)

Huang (2009)i



3 stage I
11 stage IIA–IIB
5 stage IIIA

34 (3–108)




Bleier (2009)j



1 stage I
8 stage II
1 stage IIIA

24.4 (3.6–88.4)




Midilli (2009)k



2 stage I
9 stage II
1 stage IIIA

92 (12–251)




Hackman (2009)l



4 stage I
6 stage II
5 stage IIIA–IIIB

480 (12–120)


1 retro-orbital bleed


Nicolai (2010)m


Onerci/ Andrews

5 stage I
24 stage II
17 stage III

73 (9–172)

4 (8.7%)


250–1,300 (580)

Ardehali (2010)n



21 stage IA–IIB
22 stage IIC
3 stage IIIA
1 stage IIIB

33.1 (8–74)


2 rupture of cavernous sinus, no mortality

770 (preop embolization) 1,402.6 (no preop embolization)

Frympas (2011)o



3 stage I
5 stage II
2 stage IIIA

23.7 (3–70)


1 (infraorbital nv hypoesthesia)

200–800 (444)

Lopez (2012)p



1 stage I
10 stage II





Martins (2013)q



stage I & II





El Sharkawy (2013)r



13 stage IA–IB
5 stage IIA

37.4 (14–72)




Huang (2014)s



9 stage IA–IB
17 stage IIA–IIB
24 stage IIC
16 stage IIIA–IIIB

55 (6–182)

17 (28.3%) (all stage IIB or greater)



Kopec (2014)t



8 stage IA–IB
2 stage IIA–IIB

42 (6–84)




Janakiram (2016)u



15 stage IIA





Abbreviations: Cx, complication; NR, not reported.

a Jorissen M, Eloy P, Rombaux P, Bachert C, Daele J. Endoscopic sinus surgery for juvenile nasopharyngeal angiofibroma. Acta Oto-rhino-laryngologica Belgica. 2000;54(2):201–219

b Roger G, Tran Ba Huy P, Froehlich P, et al. Exclusively Endoscopic Removal of Juvenile Nasopharyngeal Angiofibroma: Trends and Limits. Arch Otolaryngol Head Neck Surg. 2002;128(8):928–935.

c Onerci TM, Yücel OT, Oğretmenoğlu O. Endoscopic surgery in treatment of juvenile nasopharyngeal angiofibroma. Int J PediatrOtorhinolaryngol;67(2003):1219–1225

d Nicolai P, Berlucchi M, Tomenzoli D, et al. Endoscopic surgery for juvenile angiofibroma: when and how. The laryngoscope. 2003;113:775–782

e Hofmann T, Bernal-Sprekelsen M, Koele W, Reittner P, Klein E, Stammberger H. Endoscopic resection of juvenile angiofibromas—long term results. Rhinology. 2005;43:282–289

f Borghei P, Baradaranfar MH, Borghei SH, Sokhandon F. Transnasal endoscopic resection of juvenile nasopharyngeal angiofibroma without preoperative embolization. Ear, Nose & Throat Journal. 2006;85(11):740–746

g Andrade NA, Pinto JA, Nóbrega Mde O, Aguiar JE, Aguiar TF, Vinhaes ES. Exclusively endoscopic surgery for juvenile nasopharyngeal angiofibroma. Otolaryngol Head Neck Surg 2007;137: 492–496

h Gupta AK, Rajiniganth MG. Endoscopic approach to juvenile nasopharyngeal angiofibroma: our experience at a tertiary care centre. The Journal of laryngology and otology. 2008;122(11):1185–1189

i Huang J, Sacks R, Forer M Endoscopic resection of juvenile nasopharyngeal angiofibroma. Ann Otol Rhinol laryngo. 2009;118:764–768

j Bleier BS, Kennedy DW, Palmer JN, Chiu AG, Bloom JD, O’Malley BW. Current management of juvenile nasopharyngeal angiofibroma: a tertiary center experience 1999–2007. American Journal of Rhinology & Allergy 2007;23:328–330

k Midilli R, Karcı B, Akyildiz S. Juvenile nasopharyngeal angiofibroma: analysis of 42 cases and important aspects of endoscopic approach. International journal of pediatric otorhinolaryngology 2009;73(3):401–408

l Hackman T, Snyderman CH, Carrau R, Vescan A, Kassam A. Juvenile nasopharyngeal angiofibroma: The expanded endonasal approach. Am J Rhinol Allergy. 2009;23(1):95–99

m Nicolai P, Villaret AB, Farina D, et al. Endoscopic surgery for juvenile angiofibroma: a critical review of indications after 46 cases. Am J Rhinol Allergy. 2010;24(2):e67–e72

n Ardehali MM, Samimi Ardestani SH, Yazdani N, Goodarzi H, Bastaninejad S. Endoscopic approach for excision of juvenile nasopharyngeal angiofibroma: complications and outcomes. Am J Otolaryngol. 2010 Sep-Oct;31(5):343–349

o Fyrmpas G, Konstantinidis I, Constantinidis J. Endoscopic treatment of juvenile nasopharyngeal angiofibromas: our experience and review of the literature. Eur Arch Otorhinolaryngol. 2012;269(2):523–529

p López F, Suárez V, Costales M, Suárez C, Llorente JL. Treatment of juvenile angiofibromas: 18-year experience of a single tertiary centre in Spain. Rhinology 2012;50:95–103

q Martins MB, de Lima FV, Mendonça, de Jesus EP, Santos AC, Barreto VM, Santos RC Júnior. Nasopharyngeal angiofibroma: Our experience and literature review. Int Arch Otorhinolaryngol. 2013 Jan;17(1):14–19

r El Sharkawy AA. Endonasal endoscopic management of juvenile nasopharyngeal angiofibroma without angiographic embolization. Eur Arch Otorhinolaryngol. 2013 Jul;270(7):2051–2055

s Huang Y, Liu Z, Wang J, Sun X, Yang L, Wang D. Surgical management of juvenile nasopharyngeal angiofibroma: analysis of 162 cases from 1995 to 2012. Laryngoscope. 2014;124(8):1942–1946

t Kopeć T, Borucki Ł, Szyfter W (2014) fully endoscopic resection of juvenile nasopharyngeal angiofibroma own experience and clinical outcomes. Int J Pediatr Otorhinolaryngol 78: 1015–1018

u Janakiram TN, Sharma SB, Panicker VB. Endoscopic Excision of Non-embolized Juvenile Nasopharyngeal Angiofibroma: Our Technique. Indian J Otolaryngol Head Neck Surg. 2016 Sep;68(3):263–269

The Endonasal Endoscopic Transpterygoid Approach

The endonasal endoscopic transpterygoid approach (EETA) is the initial surgical gateway that allows access to a variety of lateral and posterior surgical targets, including the infratemporal fossa (ITF), lateral nasopharynx (fossa of Rosenmuller), middle cranial fossa/Meckel’s cave, cavernous sinus, petrous internal carotid artery (ICA), and foramen lacerum. We define the transpterygoid approach as one that requires either partial or complete resection of the pterygoid plates process. Its technical nuances have been previously described.33 For a better understanding of its various modification and indications, the EETA (Fig. 34.1)45 has recently been classified into zones A–E, which match the extent of the transpterygoid dissection required by the surgical target (Table 34.3).46

Table 34.3 Endonasal endoscopic transpterygoid approaches


Region removed

Approach to


Partial removal (thinning) of pterygoid process

Pterygopalatine fossa (extended)


Anterior aspect of the base of the pterygoid process

Lateral recess of the sphenoid sinus


Base of the pterygoid process with dissection of vidian canal

Petrous apex/Meckel’s cave


Partial or complete removal of the pterygoid plates with dissection of the petrous ICA

Extensive lesion requiring access to the infratemporal fossa and control of the petrous carotid artery


Partial or complete removal of the pterygoid plates with dissection of the petrous ICA and removal of the Eustachian tube

Nasopharyngeal malignancies, extensive tumors of the middle and posterior skull base (e.g., chordoma)

Abbreviations: ICA, internal carotid artery.

Source: Reproduced with permission from Kasemsiri P, Solares CA, Carrau RL, et al, Endoscopic endonasal transpterygoid approaches: anatomical landmarks for planning the surgical corridor, Laryngoscope 2013;123:811–815.

Fig. 34.1 The middle third of the clivus and petrous bone in the coronal plane. The five modular approaches are shown in the black boxes and relate to the course of the petrous ICA. The infrapetrous approaches consist of the medial petrous apex approach (Zone 1) and the petroclival approach (Zone 2). The suprapetrous approaches consist of the quadrangular space approach (Zone 3), superior cavernous sinus approach (Zone 4), and the transpterygoid/infratemporal approach (black arrow). The cavernous sinus (CS) is seen above, and the vidian canal (V) leading to the ICA is also demonstrated. Jugular vein (J). (Reproduced with permission from Kassam AB, Gardner P, Snyderman C, et al, Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa, Neurosurgery Focus 2005;19:E6.)

The most pertinent EETA types to this discussion are type D (partial or complete removal of the pterygoid plates and dissection of the petrous ICA), which is used for lesions requiring access to the infratemporal fossa and control of the petrous ICA, and type E (involving the removal of Eustachian tube in addition to the dissection involved in type D), which is used when access to the lateral nasopharynx is required.

Tumors that extend beyond Andrews stage IIIa (generally considered advanced-stage) may require staging the tumor resection. This may involve partial resection followed by a completion endonasal surgery at a later time or combination of an endonasal endoscopic approach with an external approach.

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Feb 8, 2021 | Posted by in NEUROSURGERY | Comments Off on 34 Angiofibromas and Other Vascular Tumors of the Skull Base
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