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Concurrent chemotherapy and radiotherapy are the cornerstones of curative intent treatment for nasopharyngeal cancer (NPC). When planning radiation, classic teaching is that nasopharyngeal carcinoma can involve the pterygopalatine fossa (PPF) through either direct extension or retrograde perineural spread from branches of V2, and then spread towards the middle cranial fossa via the foramen rotundum. Radiation oncologists are trained to cover this pathway by giving a prophylactic dose to the PPF, the posterior nasal cavity and maxillary sinuses, and also the foramen rotundum. Here we present a case in which the patient had disease recurrence in the bilateral orbits and ipsilateral premaxillary soft tissues despite standard therapy. This case is notable because it clearly demonstrates not just retrograde, but antegrade perineural spread (PNS) via bilateral infraorbital nerves.