## Preoperative Assessment in Nasopharyngeal Angiofibroma **Key Point:** Nasopharyngeal angiofibroma (NAF) is a benign but highly vascular tumor that requires careful preoperative planning to minimize hemorrhage and optimize surgical outcome. ### Why MRI + Angiography + Embolization? 1. **MRI advantages in NAF:** - Superior soft tissue contrast for assessing tumor extent - Evaluates intracranial extension, skull base erosion, and orbital involvement - T1/T2 characteristics help confirm diagnosis (intermediate signal, flow voids) - Better than CT for defining surgical margins 2. **Angiography + Embolization:** - Identifies feeding arteries (typically maxillary artery and ascending pharyngeal artery) - Preoperative embolization reduces intraoperative blood loss by 50–90% - Performed 24–48 hours before surgery for optimal effect - Standard of care in most tertiary centers for tumors >3 cm ### Management Algorithm ```mermaid flowchart TD A[Suspected NAF on endoscopy + CT]:::outcome --> B[MRI with contrast]:::action B --> C{Assess extent and vascularity}:::decision C -->|Large/highly vascular| D[Angiography + preoperative embolization]:::action C -->|Small/limited| E[Proceed to surgery]:::action D --> F[Surgery 24-48 hrs post-embolization]:::action E --> F F --> G[Endoscopic or open resection]:::action G --> H[Complete hemostasis + packing if needed]:::action ``` **Clinical Pearl:** Biopsy is contraindicated due to risk of severe hemorrhage; diagnosis is made on imaging + endoscopic appearance (smooth, lobulated, pulsatile mass with blanching on pressure). **High-Yield:** The classic triad is adolescent male + unilateral nasal obstruction + epistaxis. Diagnosis is clinical-radiological; biopsy is dangerous. [cite:KD Tripathi 8e Ch 12, Scott-Brown's Otolaryngology Ch 45] 
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