The Diagnostic Odyssey: Delayed Identification of Nasopharyngeal Carcinoma Presenting as Bulbar Palsy

Abstract

Nasopharyngeal carcinoma (NPC), predominantly affecting the Chinese population in Malaysia, typically presents with diverse symptoms based on the extent of primary disease and metastasis. This case study details a 66-year-old man presenting with bulbar palsy, initially manifested as left temporal headache, slurred speech, and progressive dysphagia. There was no nosebleed, ear discharge or vertigo. Initial evaluations, including MRI brain, excluded space-occupying lesions and demyelinating disease. MRI of the whole spine incidentally revealed a mass in the Fossa of Rosenmuller with locoregional bony erosion and cervical lymph node metastasis, confirmed as undifferentiated non-keratinizing squamous cell carcinoma (T4N2M0) through biopsy. This atypical presentation underscores the diagnostic challenges and the need for heightened clinical awareness of NPC. By presenting this case, we aim to highlight the importance of considering NPC in differential diagnoses for patients with bulbar palsy to avoid delayed treatment and improve patient outcomes.