Nasopharyngeal Carcinoma Masquerading As Odontogenic Pain: A Diagnostic Odyssey

This case presents a nasopharyngeal carcinoma (NPC) patient whose primary complaint was toothache, highlighting the imperative for dental practitioners to consider NPC in the differential diagnosis of unexplained dental pain. A 40-year-old woman presented to a local dental clinic with a 3-month history of blood-tinged saliva. She was diagnosed with pericoronitis of the left third molar (tooth 38) and underwent extraction with only temporary symptom relief. One month after the extraction, she developed severe pain in the left mandibular second molar (tooth 37) that radiated to the left side of her face. Despite receiving root canal treatment at another hospital, the pain persisted and progressed to left-sided facial numbness, ear pain, conductive hearing loss, and blurred vision. Dental examination revealed no periapical pathology in tooth 37, with negative pulp vitality tests in adjacent teeth. Neurological examination showed left abducens nerve palsy (House-Brackmann grade III) and asymmetric soft palate elevation. MRI with diffusion-weighted imaging revealed a 4.1×3.3 cm heterogeneously enhancing nasopharyngeal mass. The final diagnosis was NPC with distant metastases. NPC often presents diagnostic challenges due to its anatomically concealed location and nonspecific early symptoms. Given the anatomical proximity between the maxillofacial region and nasopharynx, some patients may initially present with maxillofacial symptoms and seek care in dental clinics or stomatology hospitals. Without heightened clinical vigilance and thorough differential diagnosis, such cases are prone to misdiagnosis. NPC mimics dental pain, requiring dentists to recognize neurologic/otologic red flags for timely diagnosis.