Nasopharyngeal fibrous hemangioma (JNA) is a common benign tumor of the nasopharynx, accounting for about 24.6%-40.0% of benign tumors of the nasopharynx, the incidence of which is the first. It occurs in males aged 14-25 years old, and the tumor contains abundant blood vessels, easy to bleed, so it is also known as “male adolescent hemorrhagic nasopharyngeal angiofibroma”, due to the origin of the site of the deep, anatomical relationship, the source of blood vessels is complex, although it is benign, but it is strong to invade the surrounding tissues, and with the enlargement of the tumor, it is easy to be extended to the orbital cavity, the pterygopalatine fossa, the inferior temporal fossa, the nasal cavity, and the nasal cavity. With the increase of the tumor, it can easily extend to the orbit, pterygopalatine fossa, infratemporal fossa, nasal cavity, sinus, and even intracranial, leading to serious complications. How to effectively resect the tumor, reduce the impact on the development of maxillofacial bone, reduce intraoperative bleeding and postoperative recurrence has been a difficult problem to be solved by specialists. Since Kamel reported the first case of transnasal endoscopic JNA resection in 1996, clinical practice and academic discussions on minimally invasive surgical treatment of JNA have been carried out in China and abroad. From January to December 2005, 3 patients with ABC were treated with nasal endoscopic resection, and the treatment experience is reported as follows. Yu Guo-Jing, Department of Otorhinolaryngology, Head and Neck Surgery, Affiliated Hospital of Guizhou Medical University, Guizhou, China 1 Clinical data 1.1 General data Among the three hospitalized patients, two were male and one was female, aged 16-28 years old, with an average age of 20 years. Duration of the disease was 3 months to 2 months, average 6 months. Medical history of multiple rhinorrhea in 2 cases. First nasal hemorrhage 1 case. Clinical staging was performed by coronary plus horizontal CT and nasal endoscopy of the sinuses before surgery: 1 case in stage I, 1 case in stage II, and 1 case in stage III, in which the tumor extended outward into the infratemporal fossa, temporal fossa, and lateral wall of the orbit. The tumor root was broad-based in 2 cases (the base of the tumor was located in the posterior wall of the parietal and lateral wall of the nasopharynx in 1 case, and the lateral wall of the nasopharynx alone in 1 case). One case of the tumor was of the pedunculated type. All cases were confirmed by preoperative and postoperative pathology (2 cases were diagnosed preoperatively and 1 case was diagnosed postoperatively).1.2 Surgical methods and results Controlled hypotension and tracheotomy were performed under general anesthesia in the two cases, and the nasal mucosa was fully contracted with adrenaline pads to excise the posterior end of the middle turbinate with electrocoagulation to stop bleeding, and the basal part of the tumor was exposed as much as possible. Nasal endoscopic electrocoagulation of the tumor root edge of about 3MM area, lift up the periosteum, electrocoagulation and hemostasis while peeling the tumor base along the bone surface, and use sterile gauze to the nasopharyngeal direction of pressure to push, until the root of the tumor is completely peeled off from the bone surface, and then remove it along the nasal cavity with tissue forceps. After checking that there was no tumor residue, hemostasis was strengthened, and the nasopharynx and nasal cavity were filled with iodoform gauze. In this group, one case of small tumor in the nasal cavity and the base was not wide (with tip type), using local anesthesia and surface anesthesia for endoscopic removal of fibroangioma, electrocoagulation of the tumor tip, complete stripping of the base from the surface of the bone, the range of more than the tip of the periphery of about 3mm, sieve sinus pliers and electric cutters to remove the tumor. 1 case of hemorrhagic shock 30min after surgery, 2 cases of no hemorrhage in the operation, and 2 cases of no bleeding in the operation and the postoperative period. The iodoform gauze was removed in sections after 48-72h, and 800-1200ml of blood was routinely dispensed during the operation, and those with bleeding more than 800ml were given blood transfusion, and anti-inflammatory and hemostatic treatments were given in the postoperative period. After the operation, anti-inflammatory and hemostatic treatments were given. Nasal endoscopy was carried out in the second week after the operation to check that there was no rebleeding or tumor residue. The patients were followed up for 8-12 months after the operation without recurrence. 2 Typical case: Male, 16 years old. He was admitted to the hospital with a nasopharyngeal neoplasm because of right nasal congestion with recurrent bleeding for 6 months. Examination showed that the top of the right soft palate was bulging forward, bilateral inferior turbinate hypertrophy, and a small amount of bloody secretion at the base of the right nose. There was no abnormality in the left nasal cavity. Nasal endoscopy showed a dark gray posterior end of the right nasal cavity with a smooth surface, protruding backward into the nasopharynx. The horizontal position of sinus and nasopharynx and enhanced CT showed: the right posterior nasal cavity and nasopharynx saw homogeneous enhancement of soft tissue occupying lesions, the density of the lesion was uniform, the edge was clear, the nasal septum was shifted to the left by compression, and the slope of the cranial base and the bilateral pterygoid wing were destroyed by the occupying erosion. The soft tissues of the posterior nasopharyngeal wall were not involved, and the carotid sheath area was not occupied bilaterally. Nasal endoscopic nasal tumor resection was performed under general anesthesia. The patient was lying down, general anesthesia was effective and controlled hypotension was added, jugular vein was placed and fixed, routine disinfection was performed, 30 ml of physiological saline and 2 ml of 1‰ epinephrine were added to contract the mucosa of both nasal cavities, and new organisms were seen at the posterior end of the nasal cavity, which protruded into the nasopharyngeal portion in the backward direction, with light red color and extremely tough texture, and blood sinus was visible on the surface of the section, which was easy to bleed. After careful reading of the film, the neoplasm was bluntly peeled off from the lateral wall of the neoplasm while suctioning out the blood, and at the same time, epinephrine was given to the cotton pads to pressurize and contract, and electrocoagulation was used to stop bleeding. The neoplasm invaded into the endopterygoid plate, and some of the endopterygoid plate was occluded to separate the neoplasm from the endopterygoid structure, and then separated it from the roof of the sieve, and then it went downwards to reach the posterior nasal aperture. Finally, the neoplasm was dragged out of the posterior nasal aperture and nasal cavity with Allis forceps, and the tip of the neoplasm was checked to be intact. The nasopharyngeal area was filled with cushion shaped iodoform gauze ball, the right nasal cavity was filled with iodoform and Vaseline gauze, the left nasal cavity was filled with Vaseline gauze, and the surgery was completed after checking the oropharyngeal area for no active bleeding. In the process of patient awakening, nasopharyngeal hemorrhage, hemorrhagic shock manifestation, to actively resuscitate, with gauze roll through the oral cavity direct pressure nasopharyngeal, and then transfusion of concentrated red blood cells 5U, and prophylactic tracheotomy, the patient awakened, blood pressure is normal, oropharyngeal no blood seepage, the patient was sent back to the ward in a stable condition, the operation lasted for 75min, intraoperative and postoperative bleeding of about 1,200ml, the excision of tissue sent to the hospital for disease examination after the operation. The resected tissues were sent to the hospital for examination. On the second day of the operation, the nasal tamponade was partially withdrawn, and on the fourth day, all the tamponade was withdrawn, and there was no further bleeding in the nasal cavity and nasopharynx. The postoperative pathology report was nasopharyngeal fibrovascular tumor. At 8 months after the operation, the operative cavity was epithelialized and no tumor recurrence was observed. The patient had no nasal congestion, good nasal ventilation, no nasal dryness, no nosebleed, headache, runny nose and other symptoms. 3 Discussion 3.1 Clinical characteristics of JNA JNA is a common benign tumor in the nasopharynx, with a high incidence in young males, and its main components are fibrous tissue components of variable proportions and widely branched vascular network. The vascular wall in the tumor is composed of endothelial cells only, so once the tumor ruptures, it can cause life-threatening hemorrhage, which is very dangerous. This tumor mostly originates from the posterior lateral wall of the nasal cavity near the upper edge of the pterygopalatine aperture where the posterior attachment of the middle turbinate is located, and it is easy to expand to the surrounding area, because of the deep location of the tumor, the complexity of the surrounding anatomical relationship, the main arteries are more constant, and there are a large number of poorly constricted blood vessels and tumors inside the tumor, with no peritoneal membrane and the relationship with the periphery is not clear, the surgical difficulty is greater. CT scan can understand the extent of the tumor and its invasion of bone, while MRI scan can help to understand the invasion of surrounding soft tissue and intracranial invasion. Clinical staging is mainly based on the imaging characteristics of the tumor, and enhanced CT and MRI are preferred. The diagnosis of JNA is not difficult in most cases, but some cases are easily confused with posterior nasal polyps. Usually, posterior nostril polyps are softer and more mobile, while JNA is tougher and less mobile, which can be clearly diagnosed by careful nasal endoscopy. In this group, the enhanced CT showed Chandler stage I-II. 2 of the 3 nasopharyngeal cases showed a gray-red swelling with smooth surface and vascular lines, which bled on palpation. 1 fiberoptic nasopharyngeal microscopy showed polypoid changes (pathologically diagnosed as hemangioma after surgery). 3.2 Indications for endonasal endoscopic JNA resection There is no universally recognized and authoritative indication for surgery, but Wang Wang et al, through research and experience, believe that: (1) the scope of the lesion is limited to the nasal cavity, the nasopharyngeal cavity, the parietal sinus or the sieve sinus, with partial invasion of the maxillary sinus, and even partial invasion of the pterygopalatine fossa can be considered as an indication for the surgery; (2) there is no extensive erosion of the lateral base of the skull and the involvement of the intracranial area; and (3) the Chandler staging of stages I and II can also be used. Transnasal endoscopic resection is also feasible for those with Chandler stage I and II. Surgical treatment should be performed as soon as possible after diagnosis without extensive skull base invasion. 3.3 Experiences of endoscopic DE(resection)1 At present, the treatment of DE(is mainly surgical, and the choice of surgical method should take into account the size, location, extent of invasion, effect of embolization, and experience of the surgeon, etc. Many scholars at home and abroad have used the traditional palatine resection as the main treatment for DE. Many scholars at home and abroad have boldly explored the traditional palatal route, nasal route and combined intracranial and extracranial route. In recent years, nasal endoscopic technology has become more and more mature, which has the advantages of small trauma, adequate exposure of the surgical field, small residual tumor, low recurrence rate, small bleeding, and relatively low complications. Nasal endoscopic resection is not necessary to damage the facial soft tissues, preserving the function of facial muscles and trigeminal facial nerve, and there is no need to incise the facial bone, which makes nasal endoscopic surgery significantly better than the traditional surgery in terms of minimally invasive and protection of the facial bone. In this group, all three cases were resected by endonasal endoscopic surgery, and none of them had recurrence. 3.3.1 Fully exposing the surgical field, the JNA is rich in blood supply, and most of them are trapezoidal vascular plexus, so it is necessary to operate quickly when removing the tumor, and it is also necessary to stop bleeding repeatedly during the operation. Therefore, it is extremely important to fully expose the operation field to reduce bleeding. If the anterior end of the middle turbinate extends forward too long, the anterior end of the middle turbinate can be coronal resected, so that the anterior end of the middle turbinate is basically even with its root; if the anterior end of the middle turbinate is thicker, the lateral part of the middle turbinate needs to be sagittal resected, so as to obtain a more spacious entrance to the middle nasal passage. If necessary, it is feasible to resect the hook and open the anterior and posterior sieve sinuses. After the sieve sinuses are opened, the middle turbinate can be moved outward appropriately, which is conducive to the exposure of the olfactory fissure and the posterior nostril area, and a more spacious operation space can be obtained. 3.3.2 Exploration and accurate positioning of the root and tip of the tumor: Use the peeler to explore the direction of the tumor along the surface of the tumor; if the tumor is lightly adhered to the surrounding area, the peeler can be used to gently separate the tumor from the surrounding tissues; if the adherence is heavy, the cutter and suction device can be used to separate the tumor along the side of the tumor, remove the tissues around the tumor, and then dissect the tip of the tumor step by step. When opening the posterior sieve close to the anterior wall of the pterygoid sinus, it is necessary to carefully investigate whether there is any tumor involved here, so as to prevent massive bleeding when incising the tumor. After the root tip is clearly exposed, the tumor root can be grasped with Allis forceps or loopers, and the tip can be rapidly peeled off with a peeler to remove the tumor from the nasal cavity or the oral cavity. Finally, the nasal cavity is filled with iodoform gauze bilaterally, and nasopharyngeal plugs are added if necessary. This step is the key link of nasal endoscopic JNA resection, and whether it is handled properly or not directly determines the surgical effect and postoperative recurrence. 3.3.3 Measures to reduce intraoperative and postoperative bleeding Reducing intraoperative bleeding is an important part of the smooth operation. When bleeding is high, due to the unclear anatomical markings, before the tumor tip is explored and revealed, the tumor will be injured, causing a large amount of bleeding, which will bring difficulties to the operation and easily lead to orbital and cranial complications. To maintain a clear surgical field, bleeding should be stopped properly. During the operation, the hemostatic gauze or cotton ball should be kept in the endoscopic field at all times, bleeding at any time, pressing at any time, and the principle is to keep the field clear at all times. The principle is to keep the field clear at all times. Remove blood from the field at any time, apply pressure here, and then operate elsewhere. Combine with intraoperative controlled lowering of blood pressure and other hemostatic measures. Due to the rich blood supply of JNA, intraoperative bleeding is fierce, and the operating space of nasal endoscopic JNA resection is limited, so it is inconvenient to stop bleeding. Therefore, preoperative embolization, intraoperative controlled blood pressure lowering and general anesthesia are essential measures to reduce bleeding. Usually, the vessels are embolized 2-3 d before surgery, and the embolization can block more than 90% of the blood supply to the tumor, thus reducing bleeding. In this group of cases, no embolization was performed, and intraoperative bleeding was not much, which may be due to the fact that the tumor itself has more fibrous components and relatively less vascular components. Because the intraoperative hemostatic measures are relatively perfect, but after the tumor resection, the trauma is large and the hemostatic measures are relatively single, postoperative bleeding is also possible. In this group, one case of nasopharyngeal hemorrhage occurred just after the end of the operation, and the possible causes were: (1) controlled hypotension (70/55 mmHg) was used during the operation, and the blood pressure rose after the operation; (2) the tumor was relatively large after resection, and the tumor had a relatively large wound after the operation; (3) insufficient nasopharyngeal tamponade pressure or tamponade was dislocated; and (4) the tumor was left behind. The most important emergency treatment measure in such cases is direct compression through the oral nasopharynx. Therefore, the possibility of bleeding after endoscopic JNA resection should not be ignored. According to the current report, the bleeding of endoscopic JNA resection is comparable to that of conventional surgery, such as transhiatal surgery and lateral nasal incision, and the postoperative recurrence rate is also similar to that of conventional surgery, but its minimally invasive advantage shows its good development prospect. In conclusion, the treatment of JNA is mainly based on surgery, and preoperative CT and MRI should be performed to clarify the size, location, extent, invasion of the skull base, and blood supply vessels of the tumor, and biopsy under nasal endoscopy if the nature of the tumor cannot be clarified, and super-selective arterial embolization or carotid artery ligature and controlled hypotensive anesthesia should be performed to reduce the amount of intraoperative hemorrhage. Traditional procedures include transpalatal, nasal, infratemporal fossa, and combined intracranial and extracranial routes, which are associated with many complications. Minimally invasive nasal endoscopic surgery does not have some of the disadvantages of traditional surgery and does not increase the difficulty of the operation or complications, so the combination of the two procedures will have a broader future. In selected cases of JNA, endonasal endoscopic resection is a safe and minimally invasive surgical method.