A serous effusion in one ear in an adult is not a childhood diagnosis arriving late. The eustachian tube is being obstructed by something, and until the nasopharynx has been seen the commonest benign explanation — a recent upper respiratory infection — is an assumption rather than a finding. Nasopharyngeal carcinoma classically presents this way, and the effusion may be the only symptom for months.
So the examination is nasoendoscopy, not otoscopy alone, and it is done at the first visit rather than after a trial of decongestants or a grommet. The fossa of Rosenmüller is the site to inspect specifically, and it is the site most easily passed over on a quick look. Palpate the neck at the same visit: a level II or upper posterior triangle node in an adult with a unilateral effusion changes the urgency entirely.
The risk is concentrated in populations where the tumour is commoner — southern China, south-east Asia, and in India the north-eastern states, particularly Nagaland and Manipur — but the rule is not a risk-group rule. A unilateral effusion in an adult with no identified cause warrants the nasopharynx being looked at, wherever the patient is from, and grommet insertion without that examination can delay a diagnosis by the length of time the grommet works.
- Examine the nasopharynx endoscopically in any adult with a unilateral middle ear effusion
- Inspect the fossa of Rosenmüller specifically; it is the site most easily missed on a rapid look
- Palpate the neck at the same visit — an upper cervical node changes the urgency
- Do not insert a grommet for an unexplained unilateral adult effusion before the nasopharynx has been seen
- Raise your suspicion further in patients from high-incidence regions, but apply the rule to everyone
Why it matters
A grommet relieves the symptom that was the only sign, and buys the tumour the months it takes to become obvious.
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