A 15-year-old boy has recurrent severe epistaxis and nasal obstruction. Contrast CT shows an avidly enhancing mass centred at the sphenopalatine foramen with anterior bowing of the posterior maxillary wall. What is the next best step?
The clinical and imaging pattern is characteristic of juvenile nasopharyngeal angiofibroma. Unplanned biopsy can cause major haemorrhage; vascular mapping, multidisciplinary planning and selective embolisation precede resection when appropriate.
A. Perform image-guided core biopsy after routine nasal packing: The classic vascular imaging phenotype usually permits diagnosis without biopsy; packing does not make an unplanned biopsy safe.
B. Proceed directly to endoscopic excision without mapping internal-carotid contribution: Advanced lesions can recruit ICA supply, which materially changes embolisation and operative risk.
C. Embolise every feeding vessel and defer definitive tumour treatment: Embolisation is an adjunct timed to surgery in selected patients, not definitive treatment by itself.
D. Select radiotherapy before staging because surgery is always contraindicated: Surgery is standard for many resectable tumours; radiotherapy is reserved for selected unresectable, residual or recurrent disease.
E. Stage with cross-sectional vascular imaging and plan definitive treatment without office biopsy: The clinical and imaging pattern is characteristic of juvenile nasopharyngeal angiofibroma. Unplanned biopsy can cause major haemorrhage; vascular mapping, multidisciplinary planning and selective embolisation precede resection when appropriate.
If imaging were atypical and diagnosis remained uncertain, tissue diagnosis might be required but only after vascular assessment in a controlled setting.
Independent Clinora educational material; not official JCIE content, an accredited programme, clinical advice, or a substitute for local policy and specialist judgement.
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