A 20-year-old male patient presents with unilateral nasal obstruction and recurrent bleeding for the past 1 year. Transnasal endoscopic results are shown below. [image] A contrast – enhanced CT revealed a mass extending from the posterior choana to the nasopharynx. What is the most likely diagnosis? [image]

Correct Answer: C. Nasopharyngeal angiofibroma

Nasopharyngeal angiofibroma (NAF) is a benign but locally aggressive vascular tumor that classically presents in adolescent males (10–25 years) with unilateral nasal obstruction and epistaxis. The key discriminating features here are: (1) young male patient, (2) unilateral presentation, (3) recurrent bleeding (due to rich vascularization), and (4) mass extending from posterior choana to nasopharynx on imaging. NAF arises from the sphenoid rostrum and pterygoid region, grows into the nasopharynx, and often protrudes into the nasal cavity. On endoscopy, it appears as a smooth, reddish, highly vascular mass. CT shows a lobulated mass with mixed density and intense enhancement post-contrast due to abundant blood supply. The tumor is radiosensitive and chemosensitive, making preoperative embolization and endoscopic resection the standard Indian DOC. Diagnosis is clinical and radiological; biopsy is avoided due to hemorrhage risk. NAF does not undergo malignant transformation but can cause significant morbidity through mass effect and bleeding if untreated.

Why the other options are wrong

A. Rhinoscleroma — Rhinoscleroma is a chronic granulomatous infection caused by Klebsiella ozaenae, endemic in India, presenting with progressive nasal obstruction and crusting over years. It does NOT present with acute epistaxis, does NOT show a discrete mass extending to nasopharynx on imaging, and affects older patients. Histology shows Russell bodies and foamy macrophages, not vascular tissue. This is a trap for students confusing chronic nasal pathology with NAF. B. Antrochoanal polyp — Antrochoanal polyp is a benign polyp arising from the maxillary sinus, extending through the choana into nasopharynx, typically presenting with unilateral obstruction. However, it is NON-vascular, does NOT cause recurrent epistaxis, and occurs across all age groups (not specifically adolescent males). Imaging shows a smooth, non-enhancing mass. The absence of significant bleeding rules this out despite similar anatomical location. D. Concha bullosa — Concha bullosa is an anatomical variant where the middle turbinate is pneumatized, causing nasal obstruction. It is NOT a true neoplasm, does NOT present with epistaxis, and does NOT extend into the nasopharynx. It is an incidental finding on imaging in asymptomatic patients. The clinical presentation of recurrent bleeding and a vascular mass makes this diagnosis untenable.

High-Yield Facts

Mnemonics

NAF = Young Male + Epistaxis + Nasopharynx Think Nasopharyngeal Angiofibroma when you see a young male with recurrent nosebleeds and a vascular mass in the nasopharynx. The triad of age, bleeding, and location is pathognomonic. VASCULAR MASS in Nasopharynx = NAF until proven otherwise Any highly enhancing, vascular mass extending from the posterior choana to nasopharynx in an adolescent male = NAF. Other nasopharyngeal masses (lymphoma, carcinoma) are rare in this age group and do not present with epistaxis.

NBE Trap

NBE pairs unilateral nasal obstruction with antrochoanal polyp to trap students who focus on anatomical location alone and miss the critical discriminator: recurrent epistaxis and vascular enhancement, which are pathognomonic for NAF and absent in polyps.

Clinical Pearl

In Indian ENT practice, NAF is the most common benign nasopharyngeal tumor in adolescents. Preoperative angiographic embolization (24–48 hours before surgery) is critical to reduce intraoperative bleeding and improve endoscopic resection outcomes. Recurrence rates are 5–30% depending on completeness of resection; long-term endoscopic surveillance is mandatory.

_Reference: Bailey & Love Ch. 42 (Nasopharynx); Robbins Ch. 16 (Benign Tumors of Head & Neck)_