Asymmetric Adenoid Tonsil Enlargement on Periapical Pathology Review

A 72-year-old female was referred by a general dentist for review of a periapical low-density lesion on tooth #3. The radiologist identified multiple teeth with apical pathology, but during full-volume review of the large field of view CBCT, also noted soft tissue fullness in the right side of the adenoid tonsil, resulting in asymmetry of the pharyngeal recesses (Fossae of Rosenmuller). The right pharyngeal recess was effaced relative to the left. The radiologist noted that nasopharyngeal cancer on CBCT can present with a similar appearance, as an asymmetrical enlargement of the adenoid tonsil that occludes or effaces the pharyngeal recess. Clinical evaluation by an otolaryngologist was recommended, particularly given that nasopharyngeal carcinoma is most common in older individuals and these imaging findings can precede clinical symptoms. The earliest forms of nasopharyngeal carcinoma are felt to arise in the pharyngeal recess, making this type of finding important to evaluate when included in the field of view.