A 51-year-old male presented with right facial pain of 2-years duration with no significant medical history. Atfirst, it was treated as a dental condition and multiple maxillary tooth extractions were performed to relive the pain. After dental treatment, the pain persisted and the patient was then diagnosed as having trigeminal neuralgia. The patient developed nocturnal right epistaxis of 6 months duration and, consequently, was referred to the Ear Nose and Throat (ENT) clinic for consultation. Nasofibroscopy was performed, which revealed a purple tumor occupying almost the entire right nostril. The left nostril was intact. CT and MRI imaging studies were performed to identify the nature of the mass.
CT imaging revealed a large expansive and infiltrative process involving the right nasal cavity, maxillary, sphenoidal, and ethmoidal sinuses [Figure 1]. The mass crossed the sphenopalatine foramen and extended to the pterygopalatine and pterygomaxillary fossa. The lesion also involved the inferior orbital fissure and oval foramen, reaching the ipsilateral parasellar region. At its largest diameter, the lesion measured 6 cm. There was moderate enhancement post intravenous administration. There was no evidence of regional lymphadenopathy.
Post intravenous contrast administration, MRI revealed a hyperintense soft tissue expansive process and intracranial invasion of the middle temporal fossa involving the cavernous sinuses [Figure 2]. The mass covered the major sphenoidal fissure involving the eyeball muscles, infiltrating the extra-conal orbital floor and showed PNS through maxillary nerve (CN V2) in the infraorbital foramen.
Following the results of the imaging studies, incisional biopsy was recommended confirming a "fragment of nasal adenoid cystic carcinoma" [Figure 3]. Based on the size and intracranial invasion of the tumor, the Head and Neck Tumor Board (HNTB) recommended palliative chemo-radiation therapy. Currently, the patient remains in treatment without any complications.