Perioperative Management of Pediatric Patients Undergoing Juvenile Angiofibroma Resection. A Case Series and Educational Review Highlighting Patient Blood Management.

Juvenile nasopharyngeal angiofibromas (JNA) are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. JNAs are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. 1 Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for JNA. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for pateints with JNA. We describe a contemporary and comprehensive approach in the management of patients with high grade JNA tumors. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension. Herein the authors revisit the perioperative approach to JNA management from a multidisciplinary patient blood management (PBM) perspective.