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.
- No episodes of nasal bleeding before two months but intermittent nasal discharge.
- General examination revealed no significant abnormality.
- The 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 backfilling 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 hematological 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 the nasopharynx, sphenopalatine region with extension to posterior choana of the nasal cavity.
- There was anterior bowing of the posterior wall of the ipsilateral maxillary sinus.
- What could be the probable clinical diagnosis?
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 the posterior wall of the maxillary sinus.