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 a mouth-breather and complains of difficulty during sports. On nasal endoscopy, a smooth, glistening, reddish mass is seen in the nasopharynx, extending into the nasal cavity. CT scan shows a well-defined mass with heterogeneous enhancement and bowing of the posterior maxillary wall. Angiography reveals a highly vascular lesion with feeding vessels from the maxillary artery. What is the most likely diagnosis?

Explanation

## Diagnosis: Nasopharyngeal Angiofibroma ### Clinical Presentation **Key Point:** Nasopharyngeal angiofibroma (NAF) is a benign, highly vascular tumor that classically presents in adolescent males (peak age 15–25 years) with unilateral nasal obstruction and epistaxis. ### Pathognomonic Features | Feature | NAF | Other Nasopharyngeal Masses | |---------|-----|-----------------------------| | **Age at presentation** | Adolescent males (15–25 yr) | Carcinoma: older adults; Hemangioma: variable | | **Sex predilection** | Male:Female = 4:1 | Carcinoma: slight male predominance; Hemangioma: no sex predilection | | **Vascularity** | Highly vascular (feeds from maxillary artery) | Carcinoma: moderate; Hemangioma: vascular but different pattern | | **Appearance** | Smooth, glistening, reddish, pedunculated | Carcinoma: irregular, ulcerated; Hemangioma: less organized | | **Epistaxis** | Frequent, recurrent | Carcinoma: less common; Hemangioma: variable | | **Imaging: CT** | Heterogeneous enhancement, bowing of walls | Carcinoma: infiltrative; Hemangioma: homogeneous | | **Angiography** | Intense blush, feeding from maxillary artery | Carcinoma: less intense; Hemangioma: different vascular pattern | ### High-Yield Clinical Pearls **High-Yield:** The combination of **adolescent male + unilateral nasal obstruction + epistaxis + highly vascular mass on imaging** is pathognomonic for NAF. **Clinical Pearl:** NAF arises from the posterolateral wall of the nasopharynx near the sphenopalatine foramen, which is why it often extends into the nasal cavity and causes unilateral symptoms. **Key Point:** Angiography is essential for preoperative planning because NAF is highly vascular and derives its blood supply primarily from the **maxillary artery** (branch of external carotid). Embolization is often performed 24–48 hours before surgery to reduce intraoperative hemorrhage. ### Differential Diagnosis Exclusion 1. **Nasopharyngeal carcinoma:** Typically presents in older adults (>40 years), associated with EBV and smoking; imaging shows infiltrative lesion with bone erosion; not typically pedunculated or smooth. 2. **Hemangioma:** While vascular, it is usually homogeneous on CT, lacks the characteristic male adolescent presentation, and does not show the intense angiographic blush or maxillary artery feeders. 3. **Rhabdomyosarcoma:** Rare in nasopharynx, typically presents with more aggressive symptoms and systemic signs; imaging shows infiltrative rather than well-defined mass. ### Management Outline 1. **Diagnosis:** Endoscopy + CT/MRI (avoid biopsy — high bleeding risk) 2. **Preoperative:** Angiography with embolization 3. **Treatment:** Endoscopic resection (gold standard) or external approach if large 4. **Follow-up:** Regular endoscopic surveillance for recurrence (10–30% recurrence rate) [cite:Dhingra 7e Ch 6]