Late presentation of nasopharyngeal carcinoma

Abstract

Nasopharyngeal carcinoma has a tipically insidious presentation, with often neglected signs and symptoms, thus more than 99% of patients are symptomatic on diagnostic 1. There are 5 types of presentation models: the rhinologic type (nasal obstruction, epistaxis, rhinorrhea), the otologic type (otorrhea, conductive hearing loss), the lymphatic type (bulky cervical neck masses), the neurologic type (headache, cranial nerve palsy) and the opthalmic type (diplopia due to cranial nerve involvement - III, IV and VI). These presentation models are usually singular but will become associated as the disease progresses and the tumor extends, encompassing the skull base. 
 We present the case of a 51 y.o. male with bilateral neck massess which appeared approximatively 6 months ago, recurrent epistaxis after sneezing, unilateral (right) hearing loss and otorrhea, right side hypogeusia (partial loss of taste sense) of the tongue and hypoesthesia of the right hemiface, involving the mandible and cheek. 
 Naso-pharyngeal endoscopy showed a tumor involving the right lateral wall of the rhinopharynx as well as the posterior and superior walls and extending to the sphenoid sinuses and downward to the oropharynx. The tumor encompassed the Eustachian tube orifice - and the patient had otomastoiditis with persistent suppuration, consistent with otoscopy findings. Contrast CT scans showed skull base involvement, thus explaining cranial nerve involvement (mandibular branch of V).
 The diagnosis was locally advanced disease (stage IV) and a biopsy was performed, followed by a multi-modal radiation and chemotherapy protocol.
 Case particularity: late-onset presentation with rhinologic, neurologic, otic and lymphatic signs.