Its bleeding, bleeding and bleeding..

Hollman Miller Sign

A 13-year-old male child presented to pediatric ENT unit, with chief complaints of

  • left side nasal obstruction
  • progressive and spontaneous nasal bleed,
  • continuing nasal discharge since two months.
  • intermittent episodes of headache which used to be relieved by analgesics.

Past history

  • No episodes of nasal bleeding before two months but intermittent nasal discharge.

On examination

  • General examination revealed no significant abnormality.
  • Patient had no clinical pallor
  • mouth breathing was evident, specifically complained during sleep.
  • Rigid nasal endoscopy reveals a congested, compressible mass, filling the left inferior and middle meatus, extending back filling the choana with active serous discharge with tinges of blood clots.
  • Probe test revealed no attachments in the nasal cavity.
  • There was no tenderness on palpation and no external facial deformity.
  • The oro-dental examination was normal.

Labs and Imaging

  • Routine haematological investigations were found to be within the normal limits.
  • Imaging revealed a non-encapsulated lobulated heterogeneous soft tissue mass lesion with significant enhancement on Intra Venous (IV) contrast injection
  • Mass centered in naso-pharynx, sphenopalatine region with extension to posterior choana of the nasal cavity.
  • There was anterior bowing of posterior wall of ipsilateral maxillary sinus.

Questions

  1. What could be the probable clinical diagnosis?
Juvenile Angifibroma
Parapharyngeal Malignancy
Parotid tumor
Carcinoma Maxilla

Explanation

The clinical history, imaging findings are in favor of juvenile nasopharyngeal angiofibroma.

The imaging above represents the classical radiological finding – Holman Miller Sign – Anterior bowing of posterior wall of maxillary sinus.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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