Examqo › Examqo library › Otolaryngology – Head and Neck Surgery › Rhinology and sinuses · IMLE
Juvenile nasopharyngeal angiofibroma (JNA)
An adolescent boy with one-sided nasal obstruction and recurrent nosebleeds has JNA until proven otherwise; it is a benign but highly vascular tumour that starts near the sphenopalatine foramen, is diagnosed by imaging alone (no biopsy), is embolised before surgery and is now removed mainly by an endoscopic approach.
Why it matters in the exam
The exam shows a 15-year-old boy with one-sided obstruction and bleeding, and asks what not to do: no biopsy in clinic, because of the risk of massive bleeding. CT shows a mass widening the pterygopalatine fossa and pushing the posterior wall of the maxillary sinus forward (Holman-Miller sign); MRI shows vascular "flow voids" and strong contrast enhancement. The tumour appears almost only in adolescent boys and has sex hormone receptors. Increased incidence is described in familial adenomatous polyposis. The differential diagnosis in a boy includes an antrochoanal polyp, which does not usually bleed, and rarely a malignant tumour; on imaging, JNA enhances strongly with contrast and differs from an inflammatory polyp, which does not enhance this way.
The main blood supply is from the internal maxillary artery (a branch of the external carotid); in advanced tumours branches from the internal carotid join. Embolisation of external carotid branches is done about 24 to 72 hours before surgery and reduces bleeding. Staging by Radkowski or by UPMC (which considers supply from the internal carotid and vessels remaining after embolisation) predicts surgical difficulty and the risk of recurrence.
Treatment is excision, now mainly endoscopic; tumours with wide intracranial extension are treated with combined approaches, and sometimes with radiotherapy when complete excision is dangerous. Recurrence usually comes from residual tumour in the basisphenoid and the vidian canal, so the bone there is drilled; MRI follow-up after surgery detects residual tumour. The tumour is not malignant and sometimes regresses after puberty, but this is not relied on in a tumour that causes symptoms.
Key points
- Adolescent boy, one-sided obstruction and bleeding.
- Diagnosis by imaging alone.
- Internal maxillary artery.
- Embolisation, then endoscopic excision.
- MRI follow-up for residual tumour.
Summary table
| Aspect | Detail | Meaning |
|---|---|---|
| Who | Adolescent boy | Almost only boys |
| Symptoms | One-sided obstruction and recurrent bleeding | High suspicion |
| Imaging | Widened pterygopalatine fossa, Holman-Miller, flow voids | Diagnosis without biopsy |
| Blood supply | Internal maxillary artery | Embolisation 24 to 72 hours before surgery |
| Treatment | Endoscopic excision | Combined approaches for extensive tumour |
| Recurrence | Residual tumour in the basisphenoid and vidian canal | MRI follow-up |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: ENT and head and neck surgery, Medical licensing exam (IMLE), Pediatrics.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Benign tumours of the sinonasal tract: juvenile nasopharyngeal angiofibroma
- Snyderman CH et al. A new endoscopic staging system for angiofibromas (UPMC), 2010 — Staging
- Radkowski D et al. Angiofibroma: changes in staging and treatment, 1996 — Staging
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.