Presentation
Elderly gentleman. Bilateral neck nodes and nasopharyngeal mass. Right glossopharyngeal (IX) and trigeminal (V) nerve palsies
Patient Data
Huge right sided nasopharyngeal mass with bulk dimensions of 5.6 x 4.3 cm which extends cranially to invade the right side of the cavernous sinus surrounding the C4 segment of the ICA. The tumor extends into the right carotid space with tumor circumferentially around the right internal carotid artery and posterior extension towards the right hypoglossal canal.
Tumor extends laterally to infiltrate into the right medial pterygoid muscle and posteriorly into the right longus capitis muscle in the prevertebral space. Laterally the tumor infiltrates and expands the right buccinator space.
Signal change in the right side of the clivus suggests marrow infiltration.
Fluid in the mastoids and maxillary sinuses, the former in keeping with Eustachian tube obstruction.
Large volume cervical lymphadenopathy with a 6.1 cm right submandibular and bilateral internal jugular chain nodes (levels II and III) upto 3.5 cm.
Image 1: Right internal carotid artery (red circle) with circumferential tumor.
Image 2: Tumor infiltration of the medial pterygoid muscle (blue arrows).
Image 3: Altered signal in the right side of the clivus (blue arrows) compared to the normal left side (red arrow).
Image 4: Tumor in the right side of the cavernous sinus (blue arrows) surrounding the C4 segment of the ICA and exerting mass effect on the inferior temporal lobe.
Image 5: Tumor (blue arrows) extending into and expanding the right buccinator space.
Case Discussion
This case of advanced nasopharyngeal carcinoma with skull base invasion illustrates well the anatomy of the head and neck and skull base.
Although this patient had renal impairment and could not receive post-contrast sequences the anatomy is well illustrated on the T1 and T2 fat saturation with respect to the tumor.
The annotated images show the various sites of tumor extension/invasion, especially those that enter different neck spaces.
This case illustrates trans-spatial disease. The nasopharyngeal tumor extending into the:
- right carotid space
- right masticator space
- prevertebral space
- buccinator space
and in addition, the skull base, including the cavernous sinus and clivus.
The concomitant imaging of the skull base with CT for bony delineation is a must. Unfortunately, this patient failed to attend for CT of the skull base.
Radiological stage: T4, N3a, Mx.
From a clinical perspective, the trigeminal nerve palsy is likely due to nerve involvement in the lateral wall of the right side of the cavernous sinus and the glossopharyngeal nerve from the tumor encircling the right IJV and ICA, where this nerve courses.
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