Modified Transpalatal Approach and Total Maxillary Swing Approach

Abstract

Many surgical techniques have been described for resection of juvenile angiofibroma (JA). There is a high tendency for incomplete removal of the tumor within the confines of the anterior and middle skull base. Repeat surgical procedure to remove regrowth from residual tumor is difficult and it results in high morbidity. The ease and complete onetime removal depends on perfect exposure. Excellent visualization and unhindered surgical manipulation result in successful postoperative results. The authors designed surgical technique of “modified transpalatal” and “total maxillary swing” to approach the anterior, middle, and lateral skull base for onetime complete removal of limited and advanced juvenile angiofibroma, respectively. Tumor localized to the nasopharynx, oropharynx, and sphenoid sinus without lateral extension is removed by modified transpalatal with palatal osteomucoperiosteal (POMP) flap approach. During the procedure the hard palate and, if necessary, the soft palate are reflected like a “lid,” thereby opening up the nasal cavity and nasopharynx. This provides excellent view of the tumor and helps to coagulate the feeding vessels. In contrast to the conventional procedure, no part of the bony palate is removed and discarded. Consequently, patient did not develop scarred smaller palate and palatal insufficiency in postoperative period. Total maxillary swing (TMS) approach completely opens up the origin and most extensions of extensive juvenile angiofibroma. TMS allowed removal of the tumor from the pterygoid base, basisphenoid, clivus, pterygoid canal, and other extensions. Tumor with intracranial extensions is also dealt with. Despite the extensiveness of TMS, no maxillofacial bone is lost, and the growth of the adolescent facial skeleton is not disturbed. The facial scar gradually became indistinct over time.