A 38-year-old man presents with recurrent epistaxis from the left nostril over 3 months. Anterior rhinoscopy reveals a vascular mass in the left nasal cavity. Which investigation is most appropriate to confirm the diagnosis and assess vascularity before intervention?

Explanation

## Investigation of Choice for Suspected Vascular Nasal Mass ### Clinical Context Recurrent epistaxis with a visible vascular mass in the nasal cavity raises suspicion for benign vascular lesions (angiofibroma, hemangioma) or malignancy. The investigation must characterize the lesion's vascularity, extent, and relationship to surrounding structures. ### Why MRI with Contrast and MR Angiography? **Key Point:** MRI with gadolinium contrast and MR angiography is the gold standard for evaluating vascular nasal lesions because it: - Provides excellent soft-tissue contrast resolution to delineate the mass from surrounding mucosa and bone - Characterizes vascularity (homogeneous vs. heterogeneous enhancement) - Identifies feeding vessels via MR angiography without ionizing radiation - Assesses skull base involvement and intracranial extension (critical for angiofibroma) - Guides surgical planning and determines need for preoperative embolization **High-Yield:** MRI is superior to CT for soft-tissue characterization; MR angiography replaces conventional angiography in most cases. **Clinical Pearl:** In a young male with recurrent epistaxis and a nasal mass, juvenile nasopharyngeal angiofibroma (JNA) must be ruled out—MRI with MR angiography is the standard workup. The classic "iceberg sign" (mass extending into nasopharynx with superior extension) is best seen on MRI. ### Comparison with Other Investigations | Investigation | Strength | Limitation | |---|---|---| | **MRI + MR angiography** | Soft-tissue detail, vascularity, no radiation | Contraindicated with metallic implants | | CT with bone window | Bony erosion, skull base involvement | Poor soft-tissue contrast, radiation, cannot assess vascularity reliably | | Nasal endoscopy + biopsy | Direct visualization, tissue diagnosis | Risk of hemorrhage in vascular lesions; biopsy contraindicated if angiofibroma suspected | | Doppler ultrasound | Non-invasive, real-time flow | Limited field of view, operator-dependent, poor for deep lesions | **Warning:** Biopsy of a suspected vascular lesion (especially angiofibroma) without prior imaging and hemostasis preparation risks life-threatening hemorrhage.