JNA Signs Explained | Holman Miller Sign, Chopstick Sign, Hondousa Sign, Ram Haran Sign

👃 JNA Signs - Holman Miller Sign, Chopstick Sign, Hondousa Sign, Ram Haran Sign

Juvenile Nasopharyngeal Angiofibroma (JNA) is a highly vascular benign tumor seen classically in adolescent males.

Although histologically benign, it is locally aggressive and spreads into surrounding spaces such as Pterygopalatine fossa, Infratemporal fossa, Nasopharynx and Nasal cavity.

There are several important radiological signs associated with JNA which we will discuss in this post :

• Chopstick sign
• Holman Miller sign
• Hondousa sign
• Ram Haran sign

🥢 Chopstick Sign

📌 Type of Sign

Radiological post-operative sign seen on CT PNS

🔍 What is the Sign?

• Appearance of two parallel bony lines
• Seen after drilling of the pterygoid wedge
• Typically seen in a post-operative CT scan after JNA surgery

🧠 Why does it occur?

• During JNA surgery, tumor often extends into the pterygopalatine fossa
• Adequate clearance requires drilling of the pterygoid wedge
• After drilling, the two pterygoid plates become clearly visible
• These appear like a pair of chopsticks

What does the presence of Chopstick sign indicate?

👨‍⚕️ Why is it called Chopstick Sign?

• The exposed pterygoid plates resemble a pair of chopsticks

⭐ Very Important: This is the only post-operative sign among the commonly discussed JNA signs.

🦴 Holman Miller Sign

📌 Type of Sign

Radiological sign seen on CT PNS

🔍 What is the Sign?

• Anterior bowing of posterior wall of maxillary sinus

What is the other name of Holman Miller Sign?

🧠 Why does it occur?

• JNA spreads into the pterygopalatine fossa
• Expanding tumor exerts pressure on posterior wall of maxillary sinus
• This pushes the wall anteriorly

👨‍⚕️ Eponym

Named after Holman and Miller who described this sign.

🎯 High Yield MCQs

• Typical patient of JNA - Adolescent male with recurrent epistaxis

• Biopsy is contraindicated in suspected JNA

Why is biopsy contraindicated in JNA?

What is the site of origin of Juvenile Nasopharyngeal Angiofibroma?

What is the most common presenting symptom of JNA?

💉 Treatment Pearls

• Pre-operative embolization
• Followed by surgical excision

🦷 Hondousa Sign

📌 Type of Sign

Radiological sign seen on CT PNS

🔍 What is the Sign?

• Widening of the gap between:

  • Maxillary body
  • Ramus of mandible

⭐ Indicates infratemporal fossa involvement

🧠 Why does it occur?

Tumor spread pathway in JNA:

Sphenopalatine foramen → Pterygopalatine fossa → Pterygomaxillary fissure → Infratemporal fossa

• Tumor in infratemporal fossa exerts pressure on surrounding structures

• Leads to widening between:

  • Maxilla
  • Mandibular ramus

👨‍⚕️ Eponym

Named after Hondousa

🔺 Ram Haran Sign

📌 Type of Sign

Radiological sign seen on CT PNS

🔍 What is the Sign?

• Widening of pterygoid wedge / pterygopalatine fossa

🧠 Why does it occur?

• Tumor spreads into the pterygopalatine fossa
• Causes expansion of the fossa
• Seen as widening on CT scan

⭐ Typical sign of JNA spread into pterygopalatine fossa

👨‍⚕️ Eponym

Named after Ram Haran

⚠️ Important Difference – Hondousa vs Ram Haran Sign

High Yield Rapid Revision Table

🧠 Viva Pearls

• JNA commonly arises from → Sphenopalatine foramen
• Typical patient → Adolescent male
• Most common symptom → Recurrent epistaxis
• Biopsy contraindicated in JNA
• JNA is highly vascular
• Holman Miller sign = anterior bowing of posterior maxillary wall
• Hondousa sign indicates infratemporal fossa involvement
• Ram Haran sign indicates pterygopalatine fossa widening
• Chopstick sign is a post-operative sign