Pain in the neck

Abstract

A 76-year-old man presented with a 4-week history of recurrent syncope in July, 2000. Syncope was heralded by a sensation of lightheadedness and occasionally by a mild burning sensation in the left side of his throat. Loss of consciousness was associated with urinary incontinence and generalised rigidity. There was no relationship to posture. Recovery was followed by nausea and vomiting. His past history included diabetes mellitus, peripheral vascular disease, cerebrovascular disease with left carotid endarterectomy 4 months earlier, hypertension, chronic obstructive airways disease, and excision of multiple cutaneous squamous-cell carcinomas. He was a former smoker. No significant findings were noted on examination apart from a left Horner’s syndrome attributed to the previous endarterectomy. A 12-lead electrocardiogram was normal. A computed tomograph (CT) of his head showed a small right-sided subdural haematoma without evidence of raised intracranial pressure. He was admitted to hospital. He continued to have syncopal episodes every day, associated with the absence of a palpable pulse or recordable blood pressure. Upright tilt-table testing and carotid sinus massage failed to provoke syncope. 24-h ambulatory electroencephalography was normal but 24-h Holter monitoring showed transient episodes of asymptomatic complete atrioventricular dissociation. Trials of fludrocortisone, phenytoin, salt tablets, fluoxetine, and cessation of antihypertensive therapy had no effect. An atrioventricular pacemaker was implanted and he was discharged from hospital. He returned the following day with another syncope. Pacemaker function was normal and during syncopal episodes, telemetry showed atrioventricular sequential pacing at the programmed lower rate. Cardiac catheterisation showed normal left ventricular function and a chronically occluded right coronary artery. A contrast-enhanced CT of his neck was done on the suspicion that syncope was related to a neck tumour. The CT showed a large soft-tissue mass arising from the fossa of Rosenmuller extending into the left parapharyngeal space. The tumour infiltrated the skull base and the carotid sheath with erosion of the foramen lacerum and jugular foramen, and compression of the internal jugular vein (figure). Further examination showed a midline soft palate which moved on the right side only, and slight wasting of the left sternocleidomastoid muscle. Nasoendoscopy showed left vocal cord paralysis and a large lesion in the left nasopharyngeal area. A diagnosis of malignancy with jugular foramen syndrome was made. A biopsy specimen