Per EPIC, patient initially presented on 03/20/15 with left sided ear pain and decreased hearing, found to have a left sided middle ear effusion, now s/p tympanostomy tube placement. CT temporal bone scan incidentally showed some chronic sinusitis with bony erosions with further CT evaluation of the sinuses. Left sphenoid sinusitis with bony dehiscence seen on recent sinus CT. Evaluation is limited by lack of intravenous contrast, motion artifact and an incomplete study. However, there is asymmetric soft tissue prominence in the left posterior nasal cavity extending to the left much greater than right nasopharynx with effacement of the left fossa of Rosenmuller as well as direct extension of soft tissue into the floor of the left sphenoid sinus. There is corresponding diffusion restriction. The focal bony dehiscence, adjacent osseous erosions and partially dehiscent left vidian canal are better evaluated on the prior CT. There is fluid surrounding the focal soft tissue mass in the left sphenoid sinus. Mild mucosal thickening of the bilateral maxillary sinuses, left greater than right, is also present. There is widening of the left sphenopalatine foramen and pterygopalatine fossa with loss of normal fat signal, concerning for perineural tumor spread. There is abnormal marrow signal within the left pterygoid body as well as mildly heterogenous marrow signal of the calvarium. Abnormal marrow signal is also seen basisphenoid. Left masticator space inferiorly is also involved by the mass abnormal appearance of the left medial pterygoid muscle and effacement of adjacent fat plane. The left medial pterygoid plate is not well seen, also noted on CT. There is mild asymmetric effacement of the left parapharyngeal space cranially.There is a bulky appearance along the carotid space bilaterally and partial encasement of the left internal carotid artery by the soft tissue, relating to lymphadenopathy. There is a septated heterogeneous nodule with T2 hyperintense signal measuring approximately 1.4 x 1.3 x 1.4 cm (AP x TR x CC) in the right retropharyngeal space as well as a more inferior nodule measuring 1.0 x 0.6 x 1.0 cm, which are suspicious for necrotic lymph nodes. Overall, there is increased number of prominent lymph nodes along the jugular chain bilaterally. Additional enlarged bilateral level 5 lymph nodes are present, measuring 1.6 x 1.2 cm on the right and 1.7 x 1.3 cm on the left. A left intraparotid node measures 1.3 x 0.8 cm. These all demonstrate some degree of diffusion restriction. There is mild posterior displacement of the right cervical vessels at the level of the retropharyngeal adenopathy.There is minimal scattered opacification of a few left mastoid air cells. Incidentally noted is a 4 mm pineal cyst.
1. Limited evaluation due to motion, noncontrast and incomplete study. However, prominent soft tissue thickening predominantly at the left greater than right nasopharynx extending into the posterior left nasal cavity with direct extension into the left sphenoid sinus. Additional involvement of the left masticator space and effacement of the left parapharyngeal space, with partial encasement of the left internal carotid artery by soft tissue. Findings are highly suspicious for primary nasopharyngeal neoplasm with perineural tumor spread, and necrotic metastatic right retropharyngeal lymph nodes in addition to other bilateral cervical lymphadenopathy. Evaluation of the full extent of tumor and perineural tumor spread is limited on this noncontrast study. If there are no contraindications, MRI with contrast is recommended.2. Abnormal marrow signal of the left pterygoid body, basisphenoid, and calvarium, suspicious for osseous involvement. Osseous erosive changes and focal dehiscence are better seen on prior CT. Findings discussed with Samantha Zunich, PA of Dr. Pinto's office on 6/11/2015 at 11:10 am by Dr. Wu.  