1. Nasopharyngeal Angiofibroma:
Juvenile Nasopharyngeal Angiofibroma
(JNA)
highly vascular benign yet unencapsulated tumor of adolescent males.

2. Frequency: JNA accounts for 0.05% of all head and neck tumors.
Sex: JNA occurs exclusively in males.
Age: range is 7-19 years. JNA is rare in patients older than 25 years
Etiology: A hormonal theory has been suggested due to the lesion's occurrence in adolescent males.

3. Pathophysiology:
The tumor starts adjacent to the sphenopalatine foramen. Large tumors frequently are bilobed or dumbbell-shaped, with one portion of the tumor filling the nasopharynx and the other portion extending to the pterygopalatine fossa.

5. Clinical: Symptoms:
Nasal obstruction (80-90%):
Epistaxis (45-60%):
Headache (25%):
Facial swelling (10-18%)
Other symptoms include unilateral rhinorrhea, anosmia, hyposmia, rhinolalia, deafness, otalgia, swelling of the palate, and deformity of the cheek.

6. Signs:
Nasal mass (80%)
Orbital mass (15%)
Proptosis (10-15%)
Other signs may include
-Serous otitis due to eustachian tube blockage.
-Zygomatic swelling and trismus denote spread of the tumor to the infratemporal fossa.

7. Differentials:
Other causes of nasal obstruction, (eg, nasal polyps, antrochoanal polyp, teratoma, encephalocele, dermoids, inverting papilloma, rhabdomyosarcoma, squamous cell carcinoma)
Other causes of epistaxis, systemic or local
Other causes of proptosis or orbital swelling

8. CT scan

9. Medical therapy: Surgical therapy Hormonal therapy Radiotherapy
Biopsy is prohibited because of severe bleeding

10. Nasopharyngeal malignancies
Nasopharyngeal carcinoma (NPC)
Lymphoma
Salivary gland tumors
Sarcomas

11. Nasopharyngeal Carcinoma
More common in Asia

12. Anatomy Anteriorly -- nasal cavity
Posteriorly -- skull base and vertebral bodies
Inferiorly -- oropharynx and soft palate
Laterally --
Eustachian tubes and tori
Fossa of Rosenmuller - most common location

14. Anatomy Close association with skull base foramen Mucosa
Epithelium - tissue of origin of NPC
Stratified squamous epithelium
Pseudostratified columnar epithelium
Salivary, Lymphoid structures

15. Epidemiology Chinese native (广东，广西。湖南，福建）
> Chinese immigrant > North American nativeBoth genetic and environmental factors
Genetic
HLA histocompatibility loci possible markers

16. Epidemiology Environmental Viruses Nitrosamines - salted fish
EBV- well documented viral “fingerprints” in tumor cells and also anti-EBV serologies with WHO type II and III NPC
HPV - possible factor in WHO type I lesions
Nitrosamines - salted fish
Others - chronic nasal infection, poor hygiene, poor ventilation

17. Clinical Presentation
Often subtle initial symptoms
1. unilateral HL (SOM)
2. epistaxis
3. painless, slowly enlarging neck mass
Larger lesions
4. nasal obstruction
5. cranial nerve involvement

18. Clinical Presentation
Xerophthalmia - greater sup. petrosal n
Facial pain - Trigeminal n.
Diplopia - CN VI
Ophthalmoplegia - CN III, IV, and VI
cavernous sinus or superior orbital fissure
Horner’s syndrome - cervical sympathetics
CN’s IX, X, XI, XII - extensive skull base

19. Clinical Presentation
Nasopharyngeal examination
Fossa of Rosenmuller most common location

20. Distant spread - rare (<3%), lungs, liver, bones
Regional spread
Usually ipsilateral first but bilateral not uncommon
Distant spread - rare (<3%), lungs, liver, bones

21. Radiological evaluation
Contrast CT with bone and soft tissue windows
imaging tool of choice for NPC
MRI
soft tissue involvement, recurrences
Chest CT, bone scans

22. TNM classification
Class 0: Tis N0 M0
Class I: T1 N0 M0
Class II A: T2a N0 M0
Class II B: T1 N1 M0 ; T2a N1 M0 ;
T2b N0, N1 M0
Class III: T1 N2 M0 ; T2a, T2b N1 M0 ;
T3 N0, N1, N2 M0

23. Class IV A: T4 N0, N1, N2 M0
Class IV B: any T N3 M0
Class IV C: any T any N M1

24. Treatment External beam radiation Adjuvant brachytherapy
Dose: cGy
Adjuvant brachytherapy
mainly for residual/recurrent disease

25. Treatment Surgical management
Mainly diagnostic - Biopsy
Surgical treatment
primary lesion
regional failure with local control

26. Treatment Surgical management
Primary lesion
consider for residual or recurrent disease
approaches
infratemporal fossa
transparotid temporal bone approach
transmaxillary
transmandibular
transpalatal

27. Treatment Surgical management
Regional disease
Neck dissection may offer improved survival compared to repeat radiation of the neck

28. Treatment
Chemotherapy
Immunotherapy

29. Congenital tonsillar masses
Teratoma
Hemangioma
Lymphangioma
Cystic hygroma

30. Treatment:
Laser therapy
Surgery

31. Malignant Neoplasms Most common is lymphoma Non-Hodgkin’s lymphoma
Rapid unilateral tonsillar enlargement associated with cervical lymphadenopathy and systemic symptoms

33. Treatment
Radiotherapy and chemical therapy