Surgeons Remove Extensive Skull Base Tumor in Boy Using Modified Endoscopic Approach

The tumor, a juvenile nasopharyngeal angiofibroma, had grown far beyond its usual site in the back of the nasal cavity, reaching into the infratemporal fossa, the orbit, the cavernous sinus, and even the extradural compartment of the temporal lobe. Writing in the Egyptian Pediatric Association Gazette, the team from a single institution describes the surgical challenges they faced and the technical modifications they used to overcome them, publishing their account as a case report rather than a study of outcomes across many patients.

Juvenile nasopharyngeal angiofibroma is a rare, benign but locally aggressive vascular tumor that occurs almost exclusively in adolescent males, accounting for roughly 0.05 to 0.5 percent of head and neck neoplasms. It originates from the pterygoid wedge near the sphenopalatine foramen and spreads into adjacent spaces through preformed openings in the skull base. Its dense blood supply makes surgery hazardous, since even modest manipulation can trigger substantial intraoperative bleeding. Advances in endoscopic skull base surgery and preoperative embolisation have progressively shifted management toward minimally invasive techniques, although the authors note that the role of purely transnasal endoscopic resection for tumors with extensive infratemporal fossa involvement remains under evaluation, with limited data on outcomes.

The boy in this case had no significant past medical, family, or psychological history. He presented with progressive protrusion of the left eye that had developed over one year, along with swelling of the left cheek for two months. Notably, he had none of the symptoms classically associated with this tumor: no nosebleeds, no nasal obstruction, and no ear or visual complaints. Clinical examination showed left eye proptosis with preserved eye movement and vision, together with diffuse cheek swelling. Nasal endoscopy revealed a vascular mass in the left nasal cavity extending into the nasopharynx. The authors explain that the unusual pattern of spread, directed laterally and upward rather than into the nasal airway, explains why the typical warning signs were absent, which itself posed a diagnostic challenge.

Imaging defined the full extent of the disease. Contrast-enhanced computed tomography with carotid angiography showed a well-defined, intensely enhancing soft-tissue mass measuring approximately 5.1 by 5.5 by 5.7 centimeters, centered in the left sphenopalatine fossa and extending into the infratemporal fossa, orbit, paranasal sinuses, nasopharynx, parapharyngeal space, and intracranially into the cavernous sinus and extradural temporal lobe. Magnetic resonance imaging additionally showed a heterogeneously enhancing intraosseous lesion measuring 50 by 47 by 56 millimeters in the left sphenoid bone and posterior maxillary wall, extending into the left masticator space. A diagnosis of juvenile nasopharyngeal angiofibroma at Radkowski stage III-B was established. Differential diagnoses considered included sinonasal hemangioma, hemangiopericytoma, lymphatic malformation, rhabdomyosarcoma, and lymphoma. Biopsy was deliberately avoided because of the risk of severe hemorrhage, so the diagnosis rested on endoscopy, CT angiography, and MRI.

Angiography mapped the tumor’s arterial feeders, which arose from branches of the left external carotid artery, specifically the ascending pharyngeal artery, the accessory meningeal artery, and the internal maxillary artery, as well as from the accessory meningeal artery on the right. Additional feeding vessels arose from the left internal carotid artery. The external carotid feeders were embolized preoperatively using polyvinyl alcohol particles measuring 350 to 550 micrometers together with Gelfoam, a step intended to reduce blood loss during resection. The feeders from the left internal carotid artery were deliberately left untreated because embolizing them would carry a risk of stroke. Preoperative embolisation is described in the report as standard for most of these tumors, since it reduces intraoperative bleeding, improves endoscopic visualization, and permits safer dissection near critical neurovascular structures.

The operation itself combined established endoscopic steps with two specific modifications. After informed consent from the parents, the team used a four-handed technique for tumor dissection and an endoscopic modified Denker’s approach, in which the anterior wall of the maxillary sinus is removed to create a wide trans-antral corridor toward the pterygopalatine fossa and infratemporal fossa. The main tumor bulk was addressed through inferior turbinectomy, wide maxillary antrostomy, and drilling of the anterior, medial, and posterior maxillary walls. The infraorbital neurovascular bundle was preserved. A 30-degree angled endoscope allowed the surgeons to visualize the tumor in its entirety, including the portion entering the left sphenoid sinus, eroding its lateral wall to lie in the extradural plane, and partially encasing the left internal carotid artery.

The key modification was a small incision in the left alar groove, the natural crease where the nostril meets the cheek. According to the authors, this limited external access increased the arc of rotation of the endoscope and instruments, improved the angle of approach to the far lateral tumor components within the infratemporal fossa, and enhanced instrument maneuverability during the four-handed technique. They report that this additional access potentially eliminated the need for a posterior septectomy, which was indeed not performed because a wide sphenoidotomy already provided good visualization. The tumor, whose attachment was in the left pterygoid process, was separated from the internal carotid artery using a push-and-pull technique designed to detach it atraumatically, allowing safe removal without damaging the vessel. Because the dura remained intact, no cerebrospinal fluid leak occurred and no skull base reconstruction was required.

The immediate results were favorable. Intraoperative blood loss was less than 200 milliliters, and the boy required no postoperative blood transfusion, an outcome the authors attribute in part to the preoperative embolisation. His recovery was uneventful, with no neurological or cosmetic deficits. At the two-month follow-up he remained asymptomatic, contrast-enhanced CT showed no residual disease, and histopathological examination of the excised specimen confirmed the diagnosis of juvenile nasopharyngeal angiofibroma. The alar groove scar healed well and was described as inconspicuous within the natural crease, with no alar retraction and preserved facial symmetry. The authors note that a sphenoid sinus opacity seen on the early postoperative scan was probably a collection, though the available assessment did not conclusively establish its cause, and that postoperative MRI would have been a better choice for monitoring residual or recurrent disease.

The authors are careful to frame the significance of their report narrowly. They state that the principal technical contribution lies not in the modified Denker’s procedure itself, which is already established, but in the incorporation of the alar groove incision to overcome the anatomical limits of endoscopic access to the far lateral infratemporal fossa. They suggest this may reduce the need for more extensive transfacial or preauricular-subtemporal operations in appropriately selected patients, while emphasizing that the choice of approach must be individualized according to tumor extent, vascular involvement, and the relationship of the lesion to critical neurovascular structures. They also acknowledge that an image-guided navigation system should have been used given the extensive nature of the tumor.

The limitations of the evidence deserve emphasis. This is a single case report with two months of follow-up, so it cannot establish the reproducibility, safety, or superiority of the technique, and the authors themselves state that further experience and comparative studies are necessary. What the case does demonstrate is a proof of principle: in this one patient, exclusive endoscopic transnasal excision combined with preoperative embolisation achieved complete macroscopic resection of an advanced juvenile nasopharyngeal angiofibroma with extensive infratemporal fossa, cavernous sinus, and extradural intracranial extension, avoiding a morbid open approach while producing good early cosmetic and functional outcomes.

Subject of Research: Endoscopic transnasal excision of an advanced juvenile nasopharyngeal angiofibroma with infratemporal fossa extension in an adolescent boy

Article Title: Endoscopic management of advanced juvenile nasopharyngeal angiofibroma with extensive infratemporal fossa extension: surgical challenges and technical modifications- case report

Article References: Pal, D., Kumar Sahoo, A., Binu, R., & Raje Raghuwanshi, A. (2026). Endoscopic management of advanced juvenile nasopharyngeal angiofibroma with extensive infratemporal fossa extension: surgical challenges and technical modifications- case report. Egyptian Pediatric Association Gazette, 74(1), Article 133. https://doi.org/10.1186/s43054-026-00636-y

Image Credits: AI Generated

DOI: 10.1186/s43054-026-00636-y

Keywords: juvenile nasopharyngeal angiofibroma, endoscopic skull base surgery, infratemporal fossa, preoperative embolisation, modified Denker's approach, alar groove incision, pediatric tumor surgery, cavernous sinus, case report, minimally invasive surgery, Endoscopic, management