Serous otitis media in a child is usually eustachian tube dysfunction after an upper respiratory infection. The same finding in an adult, on one side, is a different problem until the nasopharynx has been seen. Nasopharyngeal carcinoma presents this way - a painless unilateral effusion, sometimes with a neck node the patient noticed first - and it is relatively common in parts of India and among people of South-East Asian origin.
The rule is simple and worth holding absolutely: a unilateral middle ear effusion in an adult gets a nasopharyngoscopy, not a course of antibiotics and a review in six weeks. Grommet insertion without examining the nasopharynx treats the symptom of a tumour and buys it three months.
While you are there, examine the neck and ask about epistaxis, nasal obstruction, blood-stained postnasal discharge and cranial nerve symptoms - particularly a numb cheek, which reflects trigeminal involvement and is easy to miss because the patient calls it a dental problem.
- Scope the nasopharynx in every adult with a unilateral middle ear effusion
- Never insert a grommet for an adult unilateral effusion before the nasopharynx is examined
- Palpate the neck at the same visit - a node is often the first thing the patient noticed
- Ask about epistaxis, nasal blockage, blood-stained postnasal discharge and facial numbness
- Keep the threshold lowest in populations where nasopharyngeal carcinoma is common
Why it matters
The commonest way nasopharyngeal carcinoma is missed is treating the effusion it causes.
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