Imaging in the Diagnosis of Juvenile Nasopharyngeal Angiofibroma
A 14-year-old male child reported to the dental hospital with the complaint of a painful swelling in the palate that had persisted for 1 year. History revealed that the swelling was small in size in the beginning, gradually increasing in size over time. Initially, there was no pain associated with the swelling, but with an increase in size, the patient experienced pain, dysphagia, nasal obstruction, and epistaxis. There was no history of toothache and the patient's medical and dental histories are non-contributory.\nOn clinical examination, the patient appeared dull and weak with mild facial asymmetry due to a diffuse facial swelling on the right side []. The patient was febrile with a temperature of 38°, with enlarged sub-mandibular lymph-nodes which were soft, mobile, and tender on palpation.\nIntra-orally, a well-circumscribed swelling was seen confined to the soft palate in the midline. The swelling was roughly spherical in shape, with a color of the mucosa, smooth-surfaced, sessile, soft in consistency, and without any secondary changes like ulceration or discharge []. The soft palate movements were reduced. Fine-needle aspiration cytology of the palatal swelling revealed no fluid.\nAs the swelling had been present for 1 year, increasing in size, accompanied by constitutional symptoms like fever, dyspnea, dysphagia, fatigue, lymphadenopathy, and epistaxis, a provisional clinical diagnosis of aggressive soft-tissue neoplasm was made. Conventional radiographic and advanced multiplanar imaging were performed to arrive at a definitive diagnosis.\nPeriapical, maxillary occlusal, and panoramic radiographs did not reveal any bone destruction but the right maxillary sinus appeared radio-opaque, obliterating the antrum. Postero-anterior projection of the skull revealed diffuse opacification of the right antrum, with deviation of the nasal septum toward the left side. No bony destruction was, however, observed [].\nCT scan revealed a large heterodense destructive soft tissue lesion showing intense contrast enhancement []. (+25 ±35 HU pre-contrast and +60 ±120 HU post-contrast) The tumor mass was seen in the superior postero-lateral wall of the right nasal cavity, extending into the nasopharynx and adjacent pterygopalatine fossa and the right pre-maxillary space causing bowing of the posterior antral wall with erosion/destruction of adjacent bones. The infra-temporal fossa, orbit, and middle cranial fossa on the right side were also encroached by the lesion [].\nMRI showed a large, well-defined mass in the region of the pterygo-maxillary fissure and sphenopalatine foramen on the right side with a heterogeneous intensity in both T1-weighted [] and T2-weighted images []. Tiny flow voids were noted within the lesion consistent with hypervascularity []. The mass encroached into the masticator, buccal, and parapharyngeal spaces on the right side, right nasal cavity, right sphenoid sinus, floor of the middle cranial fossa, and the right cavernous sinus [].\nRight external carotid artery angiogram [] revealed the feeding internal maxillary artery and the hypervascular lesion.\nCorrelating the clinical and imaging findings, a final diagnosis of JNA was made. Biopsy was not done owing to the vascular nature and the site of the tumor mass. The patient was referred to an Otorhinolaryngologist for management.