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| CT bone window | CT with contrast | R ECA angiogram |
Diagnosis: Juvenile nasal angiofibroma
Juvenile nasal angiofibroma is a highly vascular, locally invasive tumor seen almost exclusively in teenage males. Patients present with nasal obstruction and epistaxis. It is the most common benign tumor of the nasopharynx but may be very aggressive and invade locally. The tumor may enter the pterygopalatine fossa and from there invade the masticator space, the orbit via the inferior orbital fissure, then into the middle cranial fossa via the superior orbital fissure. The sphenoid sinus is involved in 2/3 of cases. Anterior bowing of the posterior wall of the maxillary antrum as well as widening of the pterygopalatine fossa are characteristic of juvenile nasal angiofibroma. The tumor enhances strongly and flow voids may be seen on MR. Vascular supply is primarily via the internal maxillary artery off of the external carotid. Since JNA has such a characteristic clinical history and imaging appearance, the differential is very limited. Lymphoma of the nasopharynx is more commonly of the non-Hodgkin's variety. It may present as a bulky enhancing nasopharyngeal mass but would probably not cause remodeling of bone nor would it have this degree of vascularity. Rhabdomyosarcoma is more commonly seen in children less than 6 years of age but may occur in teenagers. One third of rhabdomyosarcomas involve the head and neck. They have variable enhancement and cause destruction of the skull base and posterior maxillary sinus. The finding of an enhancing, vascular, non-destructive nasopharyngeal mass in a teenage boy is strongly suggestive of juvenile nasal angiofibroma. Related Cases
