Unusual Presentation of Nasopharyngeal Angiofibroma in an Elderly Patient

Background Nasopharyngeal angiofibroma (NA) is a benign, highly vascular tumor that can be locally invasive and tends to occur almost exclusively in adolescent males, where it is termed juvenile NA (JNA). Here, we present an unusual case of a 62-year-old man with histopathologically confirmed NA. While rare cases of NA have been reported in elderly patients after the seventh decade of life, open approach has historically been utilized for removal. We report a case of JNA treated with an endoscopic-only approach to resection after preoperative embolization.

Methods Case report and review of the literature.

Case Presentation A 62-year-old man presented with 2 years of gradually worsening right-sided nasal congestion, hyposmia, hypoesthesia in the V2 distribution, and new onset epistaxis requiring urgent nasal packing. On nasal endoscopy, a right-sided mass was found obstructing the middle meatus. CT and MRI with contrast revealed an enhancing mass centered in the right nasal cavity with extension into the ipsilateral maxillary sinus, masticator space, orbit, and cavernous sinus. The mass demonstrated expansion of the pterygopalatine fossa and infratemporal fossa.

The patient underwent preoperative angiogram with embolization of the right internal maxillary artery followed by endoscopic resection of his tumor. A transpterygoid approach was used to expose the tumor and distal branches of the internal maxillary artery were ligated. The tumor was found to be pedicled to the inferior orbital fissure and cavernous sinus. After tumor removal, the surgical defect was repaired with a free septal graft. The patient did well postoperatively and was discharged on postoperative day 3. Surgical pathology confirmed the diagnosis of NA by immunohistochemistry, which was positive for androgen receptor.

Discussion Presentation of NA later in life complicates surgical resection due to a tendency toward increased tumor size and complexity of feeding blood vessels. Rare cases of NA reported in elderly patients have historically been managed with open approaches. We report a unique case of NA in an elderly patient in which a completely endoscopic approach served as a viable option for gross resection.