Imaging description

A 17-year-old boy presented with recurrent prolonged epistaxis. Axial contrast-enhanced CT (Fig. 38.1a) demonstrates an enhancing mass centered at the posterolateral wall of the left nasal cavity and extending in all directions. Bony remodeling is present with posterolateral displacement of the left pterygoid plate, contralateral deviation of the nasal septum, widening of the left sphenopalatine foramen through which the tumor extends into the pterygopalatine and infratemporal fossae, and widening of the posterior nasal aperture through which the tumor extends into the pharynx. Sagittal contrast-enhanced CT (Fig. 38.1b) demonstrates bony destruction of the anterior wall of the sphenoid sinus, filling of the nasopharynx, and extension into the oropharynx. Fluid fills the obstructed left maxillary sinus, but the sphenoid sinus is filled with enhancing tumor. The bony remodeling indicates chronicity, and the bony destruction indicates the locally invasive nature of the tumor. Figure 38.2 demonstrates no tumor opacification on angiographic injection of the left internal carotid artery. A right internal carotid artery injection was similarly negative for tumor enhancement. These injections also demonstrated that the origins of the ophthalmic arteries were from the distal cavernous segments of the internal carotid arteries, which is typical. Figure 38.3a is a pre-embolization left external carotid arteriogram that demonstrates a dense tumor blush. On more selective angiograms, multiple branches of both the left and right external carotid arteries supplied the tumor. Figure 38.3b demonstrates a post-embolization left external carotid arteriogram in which there is abrupt cut-off of embolized arteries and the tumor blush seen in Figure 38.3a is absent. Figure 38.4 demonstrates the resected tumor mass in the same orientation as in the sagittal CT and lateral angiographic images. The demographics, CT, and angiographic appearance are characteristic of a juvenile nasopharyngeal angiofibroma (JNA), and pathology confirmed this diagnosis.