Glue ear is a childhood diagnosis. In an adult it is an obstruction of one Eustachian tube, and the question is what is obstructing it. A nasopharyngeal carcinoma sitting in the fossa of Rosenmüller presents exactly this way — painless unilateral hearing loss, aural fullness, a dull retracted drum with fluid behind it — and it presents this way before it presents as a neck node.
The examination follows from that. Look in the nasopharynx: flexible nasal endoscopy in clinic, every time, not an audiogram and a review in six weeks. Palpate the neck, including level V, because a posterior triangle node in an adult with a unilateral effusion is the combination that should not be sent away. Ask about epistaxis, nasal obstruction, cranial nerve symptoms — diplopia from a sixth nerve palsy, facial numbness in the trigeminal distribution — and about hearing on the other side for comparison. Where endoscopy is not available that day, the referral is urgent rather than routine.
The common causes really are common: recent upper respiratory infection, barotrauma, allergic rhinitis, radiotherapy to the head and neck. Most adults with a unilateral effusion have one of those, and grommet insertion or watchful waiting is the right answer. The point is not to make every effusion a cancer; it is that the nasopharynx must be seen before the effusion is called benign, and that grommeting without looking is how the diagnosis gets missed for months.
This carries more weight for this readership than for most. Nasopharyngeal carcinoma is substantially more common in parts of north-east India and east and south-east Asia than in western series, and it is a curable cancer when found early.
- Perform nasal endoscopy on every adult with a unilateral middle-ear effusion before calling it benign
- Palpate the whole neck including the posterior triangle; a level V node with a unilateral effusion is a red flag combination
- Ask specifically about epistaxis, nasal obstruction, diplopia and facial numbness
- Do not insert a grommet as the first step without having seen the nasopharynx
- Refer urgently, not routinely, where same-day endoscopy is unavailable
Why it matters
A curable nasopharyngeal cancer declares itself as a one-sided glue ear, and a grommet inserted without endoscopy hides it for months.
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