Presentation
Patient presents with epistaxis and nasal congestion for 1 week.
Patient Data
CASE OF THE MONTH: This case was selected as the Case of the Month for July 2023.
CT of the head with bone window demonstrates asymmetric splaying of the right pterygopalatine fossa and erosions of the right pterygoid process and medial plate. There is asymmetric widening with smooth remodeling of the right superior orbital fissure, foramen rotundum and vidian's canal. The posterior wall of the maxillary sinus is displaced anteriorly and the mandible is laterally deviated. Following contrast administration, we see avid enhancement of the mass which is centered at the sphenopalatine foramen. The mass extends anteromedially into the nasal cavity and nasopharynx. There is also lateral invasion into the masticator space, cephalad extension into the sphenoid sinus, and posterior skull base invasion through the neural foramen into the right middle cranial fossa.
Centered at the right sphenopalatine fossa, we see an avidly enhancing mass. The mass is predominantly isointense on T1WI with interspersed areas of streaky hyperintensity most notable laterally. On T2WI, the mass is heterogenous with corresponding hypointense streaks laterally. There is no associated restricted diffusion.
Again seen is anteromedial invasion into the nasal cavity and nasopharynx. The mass extends laterally into the masticator space and cephalad into the sphenoid sinus. There is mucosal thickening and mucous secretions within the paranasal sinuses related to mass obstruction. The mass invades the skull base through the ipsilateral superior orbital fissure, foramen rotundum and vidian's canal. There is extension of tumor into the right middle cranial fossa and cavernous sinus with partial encasement of the cavernous carotid.
Preoperative digital subtraction angiography displays tumor blush predominantly supplied by the right maxillary artery.
Case Discussion
This case is a classic example of a juvenile nasopharyngeal angiofibroma which was confirmed pathologically following surgical resection. While this tumor is benign, it can be extremely locally aggressive, as demonstrated in this case.
Co Author: Daniel P. Gewolb, MD