By Dr. André Felippu
At educational platform SurgSchool, we have uploaded a highly educational video developed by the renowned rhinologist Dr. André Felippu, head of the Otolaryngology service at the Felippu Institute in Sao Paulo, Brazil. This video details an en bloc resection surgery for a juvenile nasoangiofibroma, using a transmaxillary access (Caldwell-Luc) without prior embolization.
Introduction to the Case
The case presents an 11-year-old male patient with a history of epistaxis, diagnosed with a juvenile nasoangiofibroma. Through a CT scan with contrast, a lesion with significant contrast enhancement is observed, extending to the anterior wall of the maxilla, the lateral wall of the maxilla and the posterior wall of the laryngopharynx.
Surgical Planning
The intervention begins with a traditional Caldwell-Luc incision for lateral dissection of the tumor and localization of the internal maxillary artery. Dr. Felippu chooses not to perform preoperative embolization, facilitating a more natural search for the blood vessels that nourish the tumor.
Surgical procedure
- Initial Transmaxillary Access:
- The Caldwell-Luc incision is made to access the posterior wall of the maxilla.
- The pterygomaxillary fossa is exposed in search of the internal maxillary artery.
- Identification and Ligation of Vessels:
- The posterior wall of the maxillary sinus is removed to visualize the fat of the pterygomaxillary fossa.
- The internal maxillary artery is identified and carefully ligated using cotton thread, applying proximal and distal knots to ensure hemostasis.
- Tumor Resection:
- Once the internal maxillary artery is controlled, we proceed with the resection of the tumor.
- The tumor is removed in parts through nasal, transmaxillary and transoral routes.
Postoperative Results
The postoperative period shows endoscopic images three months after surgery, revealing an absence of recurrence. One year after the intervention, the patient has a closed maxillary sinus, which is favorable, and normal tear drainage.
