A 52-year-old man with a history of hypertension presents to the ENT clinic with recurrent epistaxis over the past 3 months. Anterior rhinoscopy reveals a pulsatile mass in the posterolateral wall of the nasopharynx. Which investigation is most appropriate to confirm the diagnosis?

## Clinical Presentation and Diagnosis The patient presents with recurrent epistaxis and a pulsatile nasopharyngeal mass — classic features of **nasopharyngeal angiofibroma** or **juvenile nasopharyngeal angiofibroma (JNA)**, though the age (52 years) suggests an adult variant. ## Why Angiography is the Investigation of Choice **Key Point:** Angiography (conventional or CT angiography) is the gold standard for confirming a vascular lesion and defining its blood supply before intervention. ### Advantages of Angiography: 1. **Definitive vascular mapping** — identifies feeding arteries (typically branches of the internal maxillary artery) 2. **Therapeutic potential** — allows preoperative embolization to reduce intraoperative bleeding 3. **High sensitivity and specificity** — directly visualizes the lesion's vascular architecture 4. **Guides surgical planning** — essential before endoscopic or open resection ## Why Other Investigations Are Insufficient | Investigation | Limitation | |---|---| | **CT scan** | Excellent for anatomy and extent, but does NOT characterize vascularity or blood supply; cannot guide embolization | | **Nasal endoscopy with biopsy** | **Contraindicated** — high risk of severe hemorrhage from a vascular lesion; biopsy is dangerous and unnecessary when clinical and imaging findings are typical | | **Plain skull X-ray** | Insensitive; does not visualize soft tissue or vascular detail | **High-Yield:** In any pulsatile nasopharyngeal mass with epistaxis, **never biopsy** — always image vascularity first with angiography or CT angiography. ## Clinical Pearl The combination of **recurrent epistaxis + pulsatile nasopharyngeal mass** is pathognomonic for a vascular lesion. Angiography not only confirms diagnosis but also enables **preoperative embolization**, which significantly reduces operative blood loss and improves surgical safety.