A 49-year-old male with no known comorbidities presented to the emergency room with two episodes of nasal bleeding over the past two months. He reported gradual deterioration of vision in his right eye over the last week, accompanied by progressively worsening pain on the right side of his face. Additionally, he noted right-sided neck swelling that had been increasing in size over the past five days.
Clinical Examination:
No eye movement on the right side.
Deficit in cranial nerves III, IV, V (V1 and V2), and VI on the right side.
Blurred vision in the right eye, normal vision in the left eye.
Imaging Studies:
CT Scan of the Head and Neck with Contrast:
Large, heterogeneously enhancing soft tissue mass in the nasopharynx, predominantly on the right side, obliterating the bilateral fossae of Rosenmüller. The mass measured 7.2 × 5.5 × 3.5 cm.
Extension anteriorly into the posterior nares and superiorly into the clivus and the floor of the sphenoid sinus.
Enlarged bilateral cervical lymph nodes.
MRI of the Head and Neck with Contrast:
Lesion in the nasopharynx with complete obliteration of the bilateral fossae of Rosenmüller, measuring 7.5 × 5.3 × 4 cm.
Extension into the nasal cavity, invasion into the right cavernous sinus, and involvement of the right carotid space, with circumferential encasement of the right internal carotid artery. Posterior extension towards the right hypoglossal canal.
Lateral infiltration into the right medial pterygoid muscle and posterior invasion into the right longus capitis muscle in the prevertebral space.
Large-volume cervical lymphadenopathy, including a 6.5 cm right submandibular node and level II and III nodes measuring up to 3 cm.
Diagnosis and Staging:
Examination under anesthesia was performed, and biopsy confirmed nasopharyngeal carcinoma.
PET/CT staging showed no distant metastasis.
Treatment Plan:
The patient was started on neoadjuvant chemotherapy with Gemcitabine and Cisplatin, administered every three weeks for a total of three cycles.
A response evaluation scan was done, followed by concurrent chemoradiotherapy (CCRT) with 70 Gy in 35 fractions.
Learning Points
Symptoms of gradual vision loss and pain on the right side of the face suggest that the disease is locally advanced and invading the cavernous sinus contents. Radiology must be carefully evaluated in light of the clinical presentation.
In locally advanced tumors, nodal involvement is very common.
MRI should be considered prior to starting treatment to evaluate:
Base of skull invasion.
Intracranial extension.
Marking the gross tumor volume for radiation therapy planning.
Position of the optic nerve and chiasm.
CT scan is the best modality to rule out bony invasion.
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