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Case Report: Juvenile Nasopharyngeal Angiofibroma and a Call for Communication

Keith R. Conti, MD, Jameson M. Petrochko MD2, Jeffrey C. Bedrosian, MD, Jarrod A. Keeler, MD

Introduction Understanding and management of the juvenile nasopharyngeal angiofibroma (JNA) has expanded over the past two decades. The classic presentation of JNA is a triad of epistaxis, unilateral nasal obstruction, and a nasopharyngeal mass1. Most cases of epistaxis are appropriately managed without specialist referral; however, certain symptom constellations require further investigation. Most cases of epistaxis are due to local inflammation, infection, or trauma2-3. Epistaxis that is recurrent, severe, refractory, and posterior in origin merits otolaryngology referral, as would any physical exam findings suggestive of a mass or other structural lesion2-3. Case Report We describe the case of a patient, NE, who presented with a JNA at the age of 17 with no significant past medical history or tobacco use. His family history is significant only for lymphoma in his mother. He initially presented to the St. Luke’s University Hospital Emergency Department in August 2017 with a 1-month history of nasal/sinus congestion, frequent epistaxis, and bloody postnasal drip that was not relieved with oral acetaminophen/phenylephrine. He was treated for environmental allergies with loratadine, cetirizine, and intravenous dexamethasone in the ED and discharged with instructions to use over the counter nasal fluticasone and follow up with otolaryngology as an outpatient. Nasal endoscopy revealed enlarged left middle turbinate with complete obstruction of left choanae, floor of nose, and narrowing of right choanae. Computer tomograph of the soft tissue of the neck with contrast showed an intensely enhancing mass arising within the posterior aspect of the left nasal cavity and nasopharynx with expansion of the left pterygopalatine fossa, bony erosion and destruction of the posterior wall of the maxillary sinus, inferior wall of the sphenoid sinus, and superior aspect of the pterygoid plate without intracranial extension (Figure 1 A, B). These findings were suggestive of JNA. A magnetic resonance image (MRI) of the face with and without gadolinium enhancement was performed and supported the diagnosis of JNA (Figure 1 C, D). The patient underwent pre-operative embolization of the ipsilateral facial, sphenopalatine, and internal maxillary arteries supplying the tumor. Surgery was performed the next day using image guidance and a two-surgeon team. Significant bleeding was encountered from the pterygoid venous plexus. Estimated blood loss was 2000 mL and a total of four units of packed red blood cells and two units of fresh frozen plasma were transfused intraoperatively. NE was sent to the intensive care unit and was extubated the following morning. He was discharged in good condition on POD three with no neurological deficits. The pathology

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