---
title: "JNA Signs Explained | Holman Miller Sign, Chopstick Sign, Hondousa Sign, Ram Haran Sign"
description: "ENT notes on important radiological signs seen in Juvenile Nasopharyngeal Angiofibroma."
source: "The ENT Resident"
author: "Dr. Mausumi Das"
canonical_url: "https://www.theentresident.com/ent-notes-lectures/jna-holman-miller-chopsticks-hondousa-ramharan-sign"
categories: ["Signs, Syndromes, Triads, and Compilation Lists in ENT", "Pharynx"]
video: "https://www.youtube.com/watch?v=5R8gGNxgYD8"
image: "https://media.theentresident.com/og-images/jna-holman-miller-chopsticks-hondousa-ramharan-sign.png"
---

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

ENT notes on important radiological signs seen in Juvenile Nasopharyngeal Angiofibroma. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=5R8gGNxgYD8

## 👃 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

| Sign | Structure Involved | Meaning |
| --- | --- | --- |
| Ram Haran sign | Pterygopalatine fossa | Widening of pterygoid wedge |
| Hondousa sign | Infratemporal fossa | Widening between maxilla and mandibular ramus |

---

### High Yield Rapid Revision Table

| Sign | Type | Finding | Seen In |
| --- | --- | --- | --- |
| Chopstick sign | Radiological (Post operative) | Parallel pterygoid plates | Post-op JNA |
| Holman Miller sign | Radiological | Anterior bowing of posterior maxillary wall | JNA |
| Hondousa sign | Radiological | Widening between maxilla & mandibular ramus | Infratemporal extension in JNA |
| Ram Haran sign | Radiological | Widening of pterygopalatine fossa | JNA |

---

### 🧠 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**

---

## About This Note

This free ENT note on JNA Signs Explained | Holman Miller Sign, Chopstick Sign, Hondousa Sign, Ram Haran Sign was written by Dr. Mausumi Das and is paired with a corresponding video lecture.

Canonical page of this note: https://www.theentresident.com/ent-notes-lectures/jna-holman-miller-chopsticks-hondousa-ramharan-sign

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## Related Notes by Category

- Signs, Syndromes, Triads, and Compilation Lists in ENT: https://www.theentresident.com/ent-notes-lectures/category/signs-syndromes-triads-lists-in-ent.md
- Pharynx: https://www.theentresident.com/ent-notes-lectures/category/pharynx.md

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