An Incidental Mass on CT in an Otherwise Asymptomatic Patient With Heat Stroke

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular tumor characteristically seen in adolescent males. While benign, it may cause significant local invasion into structures including, but not limited to, the nasopharynx, sinuses, pterygomaxillary fossa, infratemporal fossa, and the skull base. Juvenile nasopharyngeal angiofibroma is often asymptomatic until extensive local spread has occurred. We report a 17-year-old male with no recent epistaxis or other symptomatic complaints consistent with JNA, but with significant invasion discovered incidentally on computed tomography (CT) imaging.

A 17-year-old male with no significant past medical history presented to the emergency department with altered mental status (AMS) secondary to heat stroke. A CT scan of the head showed an incidental large soft tissue mass in the left posterior nasal cavity extending to the medial pterygomaxillary fossa. There was no intracranial extension. Surprisingly, there was no reported epistaxis, nasal obstruction, headaches, facial swelling, facial numbness, sinus infections, or change in vision. Nasal endoscopy showed a pink vascular mass posterior to the left middle turbinate extending posteriorly to the nasopharynx. Cranial nerves, including V2, were intact. The head and neck examination was otherwise unremarkable.

Further evaluation using magnetic resonance imaging (MRI) could not be obtained due to signal voids from orthodontic braces. A fine-cut CT sinus confirmed a mass originating from the left pterygopalatine foramen that measured 3.1 cm × 2.9 cm × 3.2 cm. It extended into the medial aspect of the left masticator space causing destruction of the medial pterygoid plate. It pushed the posterior wall of the maxillary sinus anteriorly. It extended superiorly into the floor of the sphenoid sinus (Figure 1A-C). A diagnosis of JNA was made, and the tumor was considered to be grade IIC by the Radkowski criteria. ¹ The patient underwent angiography that showed multiple pterygoid branches arising from the left internal carotid and 2 enlarged branches of the internal maxillary artery supplying the tumor (Figure 1D). These were embolized successfully using polyvinyl alcohol particles. The patient underwent transnasal endoscopic resection of the tumor the following day. Cold radiofrequency ablation was used to achieve gross total resection and histopathologic examination confirmed a JNA. The patient was discharged without complications, and a follow-up MRI is planned after the braces are removed in 6 months.

Figure 1.

Imaging JNA using CT scan. Axial, sagittal, and angiographic slices demonstrating the extent and nature of the JNA. A, Asterisk demonstrates the mass within the left sphenoid sinus in a bone-windowed axial slice. In (B) broken circle and (C) arrow, the classic Holman-Miller sign is demonstrated by the anterior bowing of the posterior wall of the left maxillary sinus. D, Angiography demonstrates the vascular nature of the tumor. CT indicates computed tomography; JNA, Juvenile nasopharyngeal angiofibroma.

All adolescent males with recurrent epistaxis and/or nasal obstruction should be evaluated for a JNA. ² However, this case highlights that these symptoms may not be present at the time of diagnosis. The incidental presentation of JNA on imaging—as seen in our patient—is unusual, but may be seen increasingly with wider use of imaging. To our knowledge, this is the first report of an incidental finding of a JNA in a patient undergoing imaging for unrelated reasons. Increased use of protocol-based imaging for conditions such as AMS and headache of unclear origin has fueled a rise in detection of head and neck masses—mostly benign and noncontributory to the primary pathology. This report highlights the unusual, yet serious pathology revealed by a rule-out scan. ³ Without doubt, a JNA incidentally discovered on a CT or MRI requires aggressive surgical management to avoid more extensive invasion and destruction by the tumor.