Review Question - QID 217713

This patient, who is an immigrant from South China, presents with a subacute history of recurrent epistaxis, headache, a mass in the posterior nasopharynx, and cervical lymphadenopathy, which is concerning for malignancy. These findings are most consistent with a diagnosis of 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 Southern Chinese ancestry, where the disease is endemic. The risk of nasopharyngeal carcinoma is thought to be higher in Southern China due to genetic predisposition and diet (food containing nitrosamines, salt-cured foods, and fermented/preserved foods are thought to contribute to the risk of developing the cancer). 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 typically 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. discuss nasopharyngeal carcinoma and discuss that measurement of plasma EBV DNA has helped enable risk stratification and assess response to therapy in patients with nasopharyngeal carcinoma.

Incorrect Answers:
Answer 1: Granulomatosis with polyangiitis (GPA) is a vasculitic disease 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 make a microscopic vasculitis such as GPA less likely.

Answer 2: Lymphoma may present with cervical lymphadenopathy and systemic "B" symptoms such as fever, night sweats, and weight loss. Other signs and symptoms of lymphoma include fatigue, itchiness, and hematologic abnormalities (e.g., 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.