During a review of nasopharyngeal angiofibroma cases in your ENT department, you note that the most common presenting symptom across all patients is which of the following?

Explanation

## Most Common Presenting Symptom of Nasopharyngeal Angiofibroma **Key Point:** Recurrent epistaxis is the most common presenting symptom of nasopharyngeal angiofibroma, occurring in 50–90% of patients at presentation. ### Why Epistaxis Is Most Common 1. **Highly vascular tumor**: NAF is a benign but extremely vascular lesion with rich blood supply from the sphenopalatine artery 2. **Friable surface**: The tumor surface is prone to ulceration and bleeding with minor trauma or Valsalva maneuver 3. **Location**: Arises in the nasopharynx where venous and arterial drainage is rich; bleeding is easily noticed by the patient ### Frequency of Presenting Symptoms | Symptom | Frequency (%) | Mechanism | | --- | --- | --- | | Recurrent epistaxis | 50–90 | Friable, vascular surface; spontaneous or trauma-induced | | Nasal obstruction | 40–70 | Mass effect; often coexists with epistaxis | | Otalgia, hearing loss | 10–20 | Eustachian tube obstruction (secondary) | | Facial swelling, proptosis | 5–15 | Late presentation with orbital/skull base extension | | Palatal bulge | 5–10 | Downward extension into hard palate | **High-Yield:** Epistaxis is the **most common initial symptom** that brings patients to medical attention, making it a key screening feature. A teenage boy with recurrent epistaxis and nasopharyngeal mass should immediately raise suspicion for NAF. **Clinical Pearl:** While nasal obstruction is also very common, epistaxis is more specific and more frequently the **chief complaint** that prompts investigation. Patients often tolerate obstruction longer but seek urgent care for bleeding. **Mnemonic:** **NAFA** = **N**asal obstruction, **A**ural symptoms, **F**acial swelling, **A**ngiofibroma — but epistaxis is the **most common** entry point. ### Why Other Symptoms Are Less Common as Primary Presentation - **Nasal obstruction alone**: May develop gradually and be attributed to allergies or sinusitis; less alarming than bleeding - **Otalgia/hearing loss**: Usually occurs later as the tumor enlarges and compresses the Eustachian tube - **Facial swelling/proptosis**: Late sign indicating advanced disease with orbital or infratemporal fossa involvement [cite:Dhingra ENT 8e Ch 15]