*9.5.1 UPMC (University of Pittsburgh Medical Center)/ Snyderman, 2010*

Only valid for tumors which are preoperatively embolised (**Table 6**).



**Table 6.**

*JNA staging system by Snyderman/ UPMC, 2010 [40].*

#### **10. Treatment**

Choice of treatment depends on the size and extent of the tumor. Treatment modalities include surgical excision (open v/s endoscopic approach) and nonsurgical adjuvant therapy (embolization/hormonal/ radiotherapy) or their combination(s).

#### **10.1 Surgical treatment of JNA**

Complete excision of the entire tumor mass should be the aim of any surgical procedure and the approach selected accordingly. Though the advancements in endoscopic surgery have minimized the need for open approaches, the surgeon should be well versed with all the techniques.

#### *10.1.1 Open surgical approach*

In general, open approaches have the advantage of providing a wide exposure. But this comes at the cost of higher morbidity, increased hospital stay, and some degree of cosmetic deformity.

#### *10.1.1.1 Transpalatal approach*

This is the shortest and most direct approach for tumors limited to nasopharynx with/ without minimal extension into sphenoid sinus/ choana [41, 42].

A U-shaped incision (Wilson's incision) is made 2.5 cm anterior to the junction of hard and soft palate. Submucoperiosteal flap is elevated posteriorly till the soft palate to bare the underlying horizontal plate of palatine bone. Soft palate and hard palate are separated. Bone is removed from the posterior part of hard palate to visualize the entire nasopharynx along with the tumor.

This approach has the advantage of good post-operative healing with no visible scar.

#### *10.1.1.2 Transnasal- maxillary approach*

#### *10.1.1.2.1 Lateral rhinotomy*

Lateral rhinotomy was first described by Irwin Moore in 1917 [43].

The incision is started 5 mm anterior and superior to the medial canthus and continued inferiorly along the deepest portion of the nasomaxillary groove. At its inferior end, it is curved medially in the crease beneath the ala. Skin flaps are

#### *Juvenile Nasopharyngeal Angiofibroma DOI: http://dx.doi.org/10.5772/intechopen.95923*

elevated over the maxilla and nasal bones. Medial wall of maxillary antrum is removed.

This provides adequate exposure for tumors extending into the nasal cavity and/ or sinuses with minimal extension into the pterygopalatine fossa.

Adequate healing allows for an inconspicuous scar mark, well hidden within the facial creases.
