Question:medium
A 14yr old boy presented with nasal mass and recurrent episodes of bleeding from the mass. Investigation of choice.
A 14yr old boy presented with nasal mass and recurrent episodes of bleeding from the mass. Investigation of choice.
Show Hint
Teenage boy + nasal mass + recurrent epistaxis = angiofibroma; it is highly vascular, so never biopsy - pick the imaging that shows vascular enhancement.
Updated On: Jun 22, 2026
- Plain CT
- CT with contrast
- X Ray Caldwell view
- X Ray with Pierre view
Show Solution
The Correct Option is B
Solution and Explanation
Approach the scenario first. The single most discriminating combination here is: adolescent male + nasal mass + recurrent epistaxis. That triad should immediately make you think Juvenile Nasopharyngeal Angiofibroma, a benign but locally invasive tumour fed mainly by the internal maxillary artery.
The governing principle: in any suspected angiofibroma, NEVER biopsy first because the lesion is extremely vascular and can bleed catastrophically. Instead you confirm the diagnosis and map the tumour with imaging that shows its vascularity.
Pick the modality by what it must demonstrate. The ideal study should (1) light up the lesion because of its rich blood supply, (2) trace spread into the pterygopalatine and infratemporal fossae and toward the skull base, and (3) show the classic anterior bowing of the posterior maxillary sinus wall (Holman-Miller / antral sign). A study done WITH intravenous contrast is what produces the bright enhancement that proves the mass is vascular - so contrast-enhanced CT fits all three needs.
Eliminate the rest:
- Plain CT $\rightarrow$ shows the soft-tissue mass and bone but cannot show the diagnostic vascular blush, so it under-performs versus contrast CT.
- X-ray Caldwell view $\rightarrow$ a plain frontal-sinus radiograph; it cannot characterise vascularity or deep extension.
- X-ray Pierre view $\rightarrow$ not a recognised work-up for this tumour.
Conclusion: the investigation of choice is contrast-enhanced CT, i.e. option B.
The governing principle: in any suspected angiofibroma, NEVER biopsy first because the lesion is extremely vascular and can bleed catastrophically. Instead you confirm the diagnosis and map the tumour with imaging that shows its vascularity.
Pick the modality by what it must demonstrate. The ideal study should (1) light up the lesion because of its rich blood supply, (2) trace spread into the pterygopalatine and infratemporal fossae and toward the skull base, and (3) show the classic anterior bowing of the posterior maxillary sinus wall (Holman-Miller / antral sign). A study done WITH intravenous contrast is what produces the bright enhancement that proves the mass is vascular - so contrast-enhanced CT fits all three needs.
Eliminate the rest:
- Plain CT $\rightarrow$ shows the soft-tissue mass and bone but cannot show the diagnostic vascular blush, so it under-performs versus contrast CT.
- X-ray Caldwell view $\rightarrow$ a plain frontal-sinus radiograph; it cannot characterise vascularity or deep extension.
- X-ray Pierre view $\rightarrow$ not a recognised work-up for this tumour.
Conclusion: the investigation of choice is contrast-enhanced CT, i.e. option B.
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