A 16-year-old boy presents to the ENT clinic with a 6-month history of progressive unilateral nasal obstruction and recurrent epistaxis. His mother reports he has been experiencing headaches and a sensation of facial fullness on the right side. On examination, a smooth, pink, vascular mass is visible in the right nasopharynx. Contrast-enhanced CT shows a well-defined mass extending from the sphenoid sinus region into the nasopharynx and oropharynx, with displacement of the soft palate. There is no cervical lymphadenopathy. What is the most likely diagnosis?

Explanation

## Diagnosis: Nasopharyngeal Angiofibroma ### Clinical Presentation **Key Point:** Nasopharyngeal angiofibroma (NAF) is a benign, highly vascular tumor that presents classically in adolescent males with unilateral nasal obstruction and epistaxis. The patient's age (16 years), sex (male), and symptomatology (progressive unilateral nasal obstruction, recurrent epistaxis, facial fullness) are pathognomonic for NAF. ### Pathological Features **High-Yield:** NAF arises from the nasopharynx near the sphenopalatine foramen and grows into the nasal cavity and nasopharynx. It is a benign fibrovascular tumor composed of mature fibrous tissue and abundant vascular channels. - **Origin:** Sphenopalatine foramen region (lateral nasopharyngeal wall) - **Histology:** Benign fibrovascular lesion; NOT malignant - **Vascularity:** Highly vascular; supplied by branches of the internal maxillary artery ### Imaging Findings | Feature | NAF | Nasopharyngeal CA | Antrochoanal Polyp | |---------|-----|-------------------|--------------------| | Age | Adolescent males | Middle-aged, smoking/EBV | Children/young adults | | Vascularity | Highly vascular | Infiltrative, less vascular | Non-vascular | | Origin | Sphenoid/nasopharynx | Epithelial surface | Maxillary sinus | | Appearance | Smooth, pink, lobulated | Irregular, ulcerated | Smooth, pale, gelatinous | CT findings in this case are classic: - Well-defined mass from sphenoid sinus region - Extension into nasopharynx and oropharynx - Smooth displacement of soft palate (not infiltration) - No cervical lymphadenopathy (benign process) ### Management Approach **Clinical Pearl:** Angiography with embolization followed by surgical excision is the gold standard. Preoperative embolization reduces intraoperative blood loss significantly. **Mnemonic: VASCULAR** — Vascular tumor, Adolescent males, Sphenoid origin, Curable with surgery, Unilateral presentation, Liable to recur if incompletely excised, Angiography needed, Recurrent epistaxis. ### Prognosis - Benign but locally aggressive - Recurrence rate: 5–30% depending on completeness of excision and staging (Fisch or Radkowski classification) - No malignant potential - Spontaneous regression rare but reported after puberty [cite:Scott-Brown's Otorhinolaryngology Ch 42]