AKT · ENT/Neck & thyroidlow yield

Nasopharyngeal carcinoma

EBV-associated squamous carcinoma of the nasopharynx

Overview

A squamous-cell malignancy of the nasopharynx, strongly associated with Epstein-Barr virus and markedly more common in people of Southern Chinese/Southeast Asian descent. The classic — and most-missed — presentation is a UNILATERAL middle-ear effusion in an adult (the tumour blocks the Eustachian tube) and/or a neck node.

Recognise

UNILATERAL otitis media with effusion (glue ear) in an ADULT — the tumour obstructs the Eustachian tube
A neck lump (cervical lymph node metastasis, often the presenting sign), epistaxis/blood-stained nasal discharge, nasal obstruction
Cranial nerve palsies and headache with skull-base extension; risk factors — EBV, Southern Chinese/SE Asian ethnicity, salted-fish diet

Red flags

Any unilateral adult glue ear, a persistent neck node, or cranial nerve palsies → urgent ENT (nasendoscopy + biopsy)

Differentials & how to tell them apart

Otitis media with effusion (benign)bilateral and in children is usually benign — a UNILATERAL effusion in an ADULT must prompt postnasal-space examination

Reactive/other cervical lymphadenopathya persistent firm neck node needs FNA + a search for a primary (including the nasopharynx)

Other head & neck SCCsite of the primary differs; nasopharyngeal disease is EBV-driven and radiosensitive

Lymphomarubbery nodes ± B symptoms

Investigations

Nasendoscopy + biopsy of the postnasal space (the diagnostic step), MRI/CT for staging, EBV serology/DNA. FNA/imaging of the neck node. 2-week-wait referral.

Management

2-week-wait ENT → nasendoscopy + biopsy; treat with radiotherapy ± chemotherapy

1Refer urgently (2-week-wait) for nasendoscopy and biopsy of the postnasal space; stage with MRI + EBV studies. Treatment is radiotherapy (it is radiosensitive), often with concurrent chemotherapy.Gate: A UNILATERAL middle-ear effusion in an ADULT is nasopharyngeal carcinoma until proven otherwise → examine/scope the postnasal space rather than just managing the "glue ear"; the wrong move is to treat it as benign OME
2MDT-directed chemoradiotherapy by stage; manage the neck nodes; long-term surveillance (including EBV DNA).

Radiotherapy — the mainstay — nasopharyngeal carcinoma is radiosensitive (often with concurrent chemotherapy)

Chemotherapy (platinum-based) — concurrent/adjuvant for advanced disease

Key points

The high-yield trap: unilateral adult glue ear = look behind the nose. EBV-associated, commoner in Southern Chinese populations, presents with the neck node/epistaxis/cranial nerves, and is radiosensitive.

Monitor & prognosis

Treatment response, EBV DNA, recurrence, radiotherapy sequelae.

Radiosensitive; better when caught early, worse with skull-base/nodal spread.

Source: NICE NG12 (suspected cancer); ENT UK