An ENT case!

Q: 55 years old male originally from Tunisia without any past medical history is admitted to the ICU with severe otitis media and marked epistaxis. On clinical exam, a neck mass is noted. What is the probable diagnosis?

Answer: Nasopharyngeal carcinoma 

The objective of this question is to describe the classic triad of nasopharyngeal carcinoma, which consists of

• neck mass
• nasal obstruction with epistaxis
• serous otitis media

Other clinical features include headache, diplopia, and facial numbness, which occur due to cranial nerve involvement. A neck mass is cervical node metastasis. Any middle-aged patient, particularly a male with classically no past medical history of otitis media, should raise suspicion for nasopharyngeal carcinoma. The origin of the patient's culture and birth is also very important in making the diagnosis; the patient in the above question is from Tunisia (or neighboring Algeria and Morocco), where food is many times cooked in rancid butter and/or sheep's fat, containing butyric acid, which is a potential EBV activator and a causative agent for nasopharyngeal carcinoma.

The most endemic area is Southern China, including Hong Kong. Other high-risk areas are Southeast Asia, North Africa, the Middle East, and the Arctic. The risk remain high despite the (im)migration and takes few generations to subside with change in diet. In some of these cultures, feeding salted fish to children is common and considered a risk factor.

#oncology

#ENT

References:

1. Chang ET, Adami HO. The enigmatic epidemiology of nasopharyngeal carcinoma. Cancer Epidemiol Biomarkers Prev 2006; 15:1765.

2. Chua ML, Wee JT, Hui EP, Chan AT. Nasopharyngeal carcinoma. Lancet 2016; 387:1012.

3. Wen Y, Xu Y, Du Y, Zhan Y, Fan S. Nasopharyngeal carcinoma: epidemiology, risk factors, signaling pathways, clinical features, diagnosis, and management. Mol Biomed. 2026 Sep 17;7(1):175. doi: 10.1186/s43556-026-00590-6. PMID: 42752793; PMCID: PMC13586136.