A 16-year-old boy presents with a 6-month history of progressive unilateral nasal obstruction and recurrent epistaxis. He reports occasional blood-stained nasal discharge and mild hearing loss on the affected side. On examination, a smooth, reddish mass is visible in the nasopharynx that blanches with pressure. Contrast-enhanced CT shows a well-defined mass in the nasopharynx with intense enhancement and widening of the pterygopalatine fossa. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Nasopharyngeal Angiofibroma **Key Point:** Nasopharyngeal angiofibroma (NAF) is a benign, highly vascular tumor that presents classically in adolescent males with unilateral nasal obstruction and epistaxis. ### Diagnostic Features | Feature | Nasopharyngeal Angiofibroma | Significance | |---------|------------------------------|---------------| | **Age** | Adolescent males (10–25 years) | Pathognomonic demographic | | **Presentation** | Unilateral nasal obstruction, epistaxis | Progressive, blood-stained discharge | | **Appearance** | Smooth, reddish, blanches with pressure | Highly vascular benign tumor | | **Imaging** | Intense enhancement, widened pterygopalatine fossa | Hallmark CT/MRI finding | | **Growth** | Progressive, locally invasive | Can erode bone, extend to orbit/skull base | **High-Yield:** The combination of **adolescent male + unilateral epistaxis + nasopharyngeal mass + intense enhancement + pterygopalatine fossa widening** is pathognomonic for NAF. ### Pathophysiology 1. Benign vascular mesenchymal tumor arising from the nasopharynx near the sphenopalatine foramen 2. Highly vascular with rich arterial supply (branches of maxillary artery) 3. Locally invasive but non-metastasizing 4. Etiology unknown; possibly related to abnormal angiogenesis **Clinical Pearl:** The tumor **blanches with pressure** due to its rich vascularity and compressible nature — this distinguishes it from solid malignancies. ### Management Approach ```mermaid flowchart TD A[Nasopharyngeal Angiofibroma diagnosed]:::outcome --> B[Staging: CT/MRI + angiography]:::action B --> C{Extent of disease?}:::decision C -->|Small, localized| D[Endoscopic resection]:::action C -->|Large, extensive| E[Preoperative embolization]:::action E --> F[Surgical resection]:::action D --> G[Histopathology confirmation]:::outcome F --> G G --> H[Follow-up for recurrence]:::action ``` **Key Point:** Preoperative angiographic embolization reduces intraoperative bleeding and is standard for large tumors. Endoscopic resection is the gold standard for accessible lesions. **Warning:** Do NOT confuse with nasopharyngeal carcinoma (older patients, squamous cell, associated with EBV in endemic areas, no blanching). [cite:Scott-Brown's Otorhinolaryngology Ch 15]