45-year-old male presented with 6 months of progressive right nasal obstruction and blood-stained nasal discharge. He developed right-sided hearing loss and tinnitus 5 months ago. One month ago, he noticed hoarseness of voice, difficulty swallowing, and a painful right neck mass. Examination found restricted movement of the soft palate and right vocal cord with an enlarged right neck lymph node. Differential diagnoses included nasopharyngeal carcinoma and sinus malignancy. CT scan and biopsy were requested to investigate.

1. Case
presentation

2. Presented by
Dr. Razan Tariq

3. Personal
history
Name: M.A.I.M
Age : 45 years
Gender : Male
Residence: Eljazeera
Occupation: Grazer

4. C/o
Right nasal obstruction /6months
Right decrease hearing/5 months
Change of voice /1 month

5. History of presenting illness:
The condition started 6 months ago
with right side nasal obstruction,
insidious onset , start on and off
progressively become constant before
1 month. No aggravating or relieving
factors, associated with ipsilateral
blood stained nasal discharge. There is
nasal regurgitation, snoring and post
nasal dripping, no mouth breathing,
SOB or obstructive sleep apnoea.

6. 1 months latter he developed right side
epistaxis ,2-3 times, small amount , start
and stopped spontaneously ,Last attack
before week. There is right side facial pain
and numbness.
No smell disturbance, no itching or
sneezing.
No dental pain, no loose or lost teeth

7. 5months ago, he developed progressive
decrease hearing, associated with severe
tinnitus(all over the day) which is roaring
in nature, and aural fullness. No vertigo,
no ear pain or discharge, no mouth
deviation.
1 month latter he developed severe
headache, dull aching, at temporal area
,no specific time of day, no aggravating
factors relieved by analgesia. No projectile
vomiting, no convulsions ,no loss of
consciousness or change in behavior.

8. There is blurring of vision and ,double
vision, no epiphora or eye protrusion

9. 1 month latter he noticed right side neck
mass, painless, gradually increase in size,
no other masses. Also he developed
,change of voice in form of hoarseness,
and chocking.
No sore throat ,odynophagia or dysphagia.
No loss of weight or appetite, no chronic
cough, no fever or sweating.

10. Systemic review:
C.P.S:
G.I.T :
GNU :
MSK :

11. Past medical history:
No past history of similar condition
No history of hospitalization or
irradiation.
Not diabetic , hypertensive or
asthmatic.

12. 
Family history:
No family history of similar
condition or chronic illness .

13. Drug history:
Not known to be allergic to aspirin or
any drug known by him.
Not on long term medication.

14. Social history:
Not known to be smoker or
alcoholic consumer
low socioeconomic status, no
health insurance.

15. summary
45 years old male presented with RT side
progressive nasal obstruction/6 months, associated
with blood stained nasal discharge. Epistaxis and
facial pain. 1 months latter he developed RT side
progressive decrease hearing and aural fullness
associated with severe roaring tinnitus.
1 months ago he developed hoarseness of voice
,nasal regurgitation for water and chocking.
There is RT side painless progressive neck mass
for1 month .no other masss.

16. Examination

17. General examination:
Pt look unwell , not pale, jaundice or
cyanosed
RR: 17 cycle/min
PR: 90 b/min
BP: 120/75
.

18. Nose normal in shape ad contour.
No area of tenderness.
Cold spatula test:
Decrease fogging in RT side
present in Left side
Nasal
examination

19. Anterior rhinoscopy: Normal vestibule
and columella bilaterally. There is blood
stained purulent nasal discharge at RT
side.
Normal mucosa covering septum ,middle
and inferior turbinate, bilaterally.
Posterior rhinoscopy: difficult

20. Eye Examination:
Normal vision and visual field

There Is opthalomplegia to lateral rectus

21. Oral examination :
Normal lips, normal teeth, gums
and buccal mucosa. Tongue
deviated to right.
Normal hard palate
Soft palate mobility restricted at
right.
Uvula deviated to left.

22. Ear examination :
Both auricles were normal . No pre or post
auricular swelling or scar , normal external
auditory canals bilaterally. No area of
tenderness
TM bilaterally dull and immobile.
-Rhine's test : -ve in RT .
Weber test is Lateralized TO RT .

23. Neck examination :
There is right side lymph nodes at level 2
and 5.largest one about 6*4 cm ,rounded,
skin over it is normal. Rounded6*4 cm, firm
in consistency,not attached to skin or deep
structures.
No limitation in neck movement .
Laryngeal crepitus is present .
Trachea central.

24. Normal base of tongue , vallecullae,
RT vocal cord restricted in mobility, LT
normal , pyriform fossae free


25. * NPC
*Sino nasal malignancy.
Differential diagnosis :

26. Investigations:
General investigation:
C.B.C
H.B : 15.1 gdl
TWBC : 5 .4
U.G : normal

27. Imaging
CT scan : Neck from base of skull to
upper chest.
MRI requested.

30. 
Biopsy taken from nasopharynx

31. .

THANKS FOR LISTINING