Nasopharyngeal carcinoma is a common encounter in otorhinolaryngology. It is a non-lymphomatous squamous cell carcinoma that occurs in the epithelial lining of the nasopharynx and shows varying degrees of differentiation. The aetiology is multifactorial. The disease is more common in the Chinese, those exposed to Epstein–Barr virus and in individuals with environmental factors, such as cigarette smoking, consumption of salted fish or preserved vegetables containing volatile nitrosamine, and exposure to industrial fumes or household smoke. Signs and symptoms include neck swelling, hearing loss, nasal blockage, epistaxis, cranial nerve palsy, headache, neck pain, earache or discomfort, weight loss and central nervous system manifestation when distant metastasis is present. Amongst these manifestations, 60% of patients will present with cervical lymphadenopathy followed by epistaxis which occurs in 40% of cases. However, distant site involvement uncommonly becomes the sole presenting symptom. We report a 58-year-old Chinese patient with nasopharyngeal carcinoma who presented with bilateral lower limb weakness. The patient was initially seen by an orthopaedic surgeon, with various radiological investigations conducted, including magnetic resonance imaging. Metastatic lesions were detected at the lumbar vertebra, sacrum and iliac bone. After positron emission tomography, a suspicious primary malignant lesion was detected in the nasopharynx and its biopsy confirmed the diagnosis of nasopharyngeal carcinoma. The patient was referred to the oncology team for definitive treatment, but refused further therapy.