An 11-year-old boy presents to the physician's office with difficulty breathing through his right nostril for several months and a 3-week history of recurrent severe nosebleeds on the same side. The patient denies any recent trauma. His parents have given him nasal decongestants and allergy medication with no relief. There is no personal or family history of serious illness. His temperature is 37°C (98.6°F), pulse is 90 beats/min, respirations are 20/min, and blood pressure is 110/80 mm Hg. Physical examination of the nose shows septal deviation to the left and a pink, lobulated mass in the right nasal cavity that is actively bleeding. The remainder of the examination shows no abnormalities.
Which of the following is the most likely diagnosis?
A) Arteriovenous malformation
B) Foreign body
C) Juvenile nasopharyngeal angiofibroma
D) Nasal hematoma
E) Nasal steroid overuse
C) Juvenile nasopharyngeal angiofibroma
Juvenile nasopharyngeal angiofibroma (JNA) typically presents with difficulty bleeding through the nose and epistaxis, though rhinorrhea may also occur. More advanced cases can present with headache, blindness, hearing problems, or speech problems. It is seen as a large friable pink nasal mass that often causes obstruction of the nasal passage and septal deviation. These tumors are benign but are often rapidly expanding, invasive, and tend to bleed very easily. They are found exclusively in males and most typically occur between the ages of 10 and 20 years. Diagnosis is confirmed with a CT scan or MRI showing a nasal mass arising from the roof of the nasopharynx. Local involvement of the nasal cavity and paranasal sinuses may be extensive, with occasional invasion of the skull base. The other answer choices may cause epistaxis, but the history and examination findings are most consistent with juvenile nasopharyngeal angiofibroma.
Key Learning Point
Juvenile nasopharyngeal angiofibroma typically presents with nasal obstruction and epistaxis and is seen as a pink, friable nasal mass on physical examination. These tumor are benign but local involvement as well as invasion of other structures can be seen.
