67-year-old man re-attended A&E following minor head injury with disproportional symptoms of dizziness on sitting upright, vomiting and neck pain. He is also complaining of nasal blockage for past 1 year with anosmia and occasional yellow rhinorrhoea. On examination he has mild neck tenderness and cranial nerves were intact. Nasopharyncoscopy revealed fullness of posterior nasal space.
Head CT was performed revealing extensive soft tissue tumour appeared to be arising from nasopharynx with extension involving cavernous sinus, jugular foramen and posterior maxillary structures. Of note at this stage was the intact pituitary fossa, which was later confirmed on MRI.
Over the subsequent 4 days he deteriorated with dysphagia with loss of gag reflex. He developed stridor secondary to bilateral vocal cord palsy requiring emergency tracheostomy. Patient also has cranial nerve palsies (IX, X, XII) which were felt to relate to increased pressure on jugular foramina.
A posterior nasal biopsy was performed and serum hormone levels were taken. Histology confirmed a neuroendocrine neoplasm with positive NSE chromagranin and synaptophysin. Histopathology opinions confirmed that there were multiple mitoses and malignant properties in the specimen and a pituitary carcinoma was the most likely diagnosis. A prolactin level of 91,682 supported this. A low testosterone and thyroid status was treated and the growth hormone and cortisol levels were normal. Through MDT discussion with Endocrine, Neuro surgical and Head and Neck specialities cabergoline therapy and a course of fractioned radiotherapy were planned.
Improvement has been slow but steady. Headache and neck pain have eased and his PEG feeding continues as cranial nerve palsies persists. His prolactin levels dropped dramatically to 227 by 3 weeks after admission. He was discharged with cabergoline and octreotide for additional prolactin secretion suppression.
He reattended clinic after 3 months with with new onset left lateral rectus weakness and his repeat MRI showed the tumour size had regressed but there is a dislocation of odontoid process through foramen magnum with compression of brain stem. He had spinal destabilisation under spinal surgeons and discharged back to nursing home. There appear to be no cases in the literature of pituitary carcinoma extending to post nasal space or affecting jugular foramina to cause cranial nerve palsies.