Review Question - QID 221213

This patient with a subacute history of recurrent epistaxis, a mass in the posterior nasopharynx, and cervical lymphadenopathy, most likely has a malignancy. In the setting of far eastern heritage and mononucleosis infection, these findings are most consistent with nasopharyngeal carcinoma.

Nasopharyngeal carcinoma is a squamous cell carcinoma of the nasopharynx that may extend into the skull base and palate. Risk factors for nasopharyngeal carcinoma include East and Southeast Asian heritage, where the risk is thought to be higher due to genetic predisposition and a diet containing nitrosamines, salt-cured foods, and fermented dishes. Epstein Barr virus (EBV) infection is another risk factor for the development of nasopharyngeal carcinoma. Symptoms of nasopharyngeal carcinoma include headache, diplopia, epistaxis, recurrent otitis media, and nasal obstruction. Physical exam reveals a nasal mass and cervical lymphadenopathy, which indicates local metastasis. Further diagnosis may be made using imaging and biopsy. The treatment involves a combination of radiation therapy, chemotherapy, and surgical excision.

Wong et al. review the evidence regarding the diagnosis and management of nasopharyngeal carcinoma. They discuss how the measurement of plasma EBV DNA has helped enable risk stratification for these patients. They recommend assessing response to therapy in patients with nasopharyngeal carcinoma using this method.

Figure/Illustration A is a clinical photograph demonstrating a heterogenous mass with necrotic features (red circle). This finding is consistent with a diagnosis of nasopharyngeal carcinoma.

Incorrect Answers:
Answer 1: Granulomatosis with polyangiitis (GPA) is a vasculitis that presents with epistaxis, sinusitis, dyspnea, joint pain, and glomerulonephritis. This patient's lack of systemic manifestations and presence of cervical lymphadenopathy concerning for malignancy makes a microscopic vasculitis such as GPA less likely.

Answer 2: Lymphoma may present with cervical lymphadenopathy and systemic symptoms such as fever, night sweats, and weight loss. Other signs and symptoms of lymphoma include fatigue, itchiness, and hematologic abnormalities such as anemia or thrombocytopenia.

Answer 3: Mucormycosis is a fungal infection that may occur in patients with poorly controlled diabetes or in patients who are immunocompromised. Rhinocerebral mucormycosis causes facial swelling, headache, nasal congestion, and fever. Physical exam of mucormycosis reveals rapidly progressive black lesions on the nose and mouth.

Answer 4: Nasal polyps are non-cancerous growths that may be found in the lining of the nose and sinuses. They are most often found in patients with asthma, allergies, chronic rhinosinusitis, and cystic fibrosis. This patient's cervical lymphadenopathy and history are concerning for a malignant process.

Bullet Summary:
Nasopharyngeal carcinoma presents with epistaxis, headache, nasal fullness, nasal mass, and cervical lymphadenopathy.