Eustachian Tube Blockage, Otitis Media and Nasopharynx Tumors

 

If you’re of adult (we’re talking chronologic, not mental) age and have fluid clogged behind your eardrum that won’t go away no matter what medicine or measures you’ve taken to clear it, then you ought to have your nasopharynx checked.

“What?  Speak English doc!”  I can hear the outbursts in virtual world.

Ah the joys of being a doctor.  Let me explain further.  The nasopharynx is the space way far back in the nose.  It’s the most posterior (rear) part of the nose and lies above the palate (roof of the mouth).  It ends below the palate at the back of your throat.  Just take a look at the darn picture above.  You can’t see the nasopharynx yourself.  In fact, many docs can’t see it, but we have nifty ways of viewing it which we’ll describe below.

The eustachian tubes are found in the nasopharynx, one on each side.  I’ll abbreviate eustachian tube as ET because as you can imagine, having to write “eustachian tube” over and over again can be a real pain in the gluteus maximus, another term that gets tiresome writing repeatedly.  In the same spirit, nasopharynx is abbreviated as NP.

 

As explained in The Eustachian Tube Part 1, a closed ET causes negative middle ear pressure, resulting in a retracted TM but also trapped fluid.  If the fluid is non-infected or nonpurulent (where purulent = pus.  “Yuck!” is an acceptable reaction), it often is not painful, but causes other not-so-pleasing symptoms as a sensation of ear plugging or fullness and hearing loss and the sense of needing to clear the ear by various means.  If this persists, this is termed chronic otitis media.  More specifically, it is called chronic otitis media with effusion where effusion = fluid, and yes, more jargon and the reason medical school and residency take so long.  The common abbreviation for this term--which I refuse to write again--is COME.

The ET usually matures by 4 years of age, and so otitis media, both acute (where there is pus behind the eardrum) and COME is mostly a disease of childhood.  However, COME is not that uncommon in adults, especially after a hefty cold or when travelling through changing altitudes, such as flying or driving through mountain passes. 

If an adult has a COME, namely if there is persistent fluid in the middle ear (the space behind the ear drum, abbreviated ME), and you’ve been treated with stuff such as decongestants, antihistamines, antibiotics, nasal steroid sprays, nasal decongestant sprays (beware of using these too long), ear candling (inadvisable since they don’t work), or whacking your head on the table (again, inadvisable) then the NP must be checked.  Though most often COME is related to a closed ET that cannot overcome the negative pressure within the ME, there could be something mechanically blocking the ET, such as a tumor.  By the way, tumor = “not good.”

This is vital, since treating the ear alone by draining the fluid with a myringotomy and tube only alleviates the symptoms, and you could be missing a whopping problem that can be life threatening if left untreated.

Thus, whenever I see an adult with COME that does not resolve after a month or longer, I always check the nasopharynx.  Sometimes this can be done with a dental mirror looking up and behind the soft palate, but the majority of the time this is inadequate.  More often, a fiberoptic nasopharyngoscopy is needed.  Don’t be scared by this term: the procedure is brief and well-tolerated by most folks

 

More often than not, the nasopharynx is unremarkable.  However, during the course of my career, I’ve found tumors in the nasopharynx of adults, and the only finding was COME.   Most were nasopharyngeal carcinomas (malignant tumors arising from the epithelial cells of the NP), but there were a few lymphomas (malignant tumors arising from lymphoid tissue, such as the adenoid, found in back in the NP).  Treatment varies by the type of cancer and its extent (stage), and often includes radiation and chemotherapy.

The photo below shows a gentleman with left COM lasting several months.  I did a fiberoptic and sure enough, I noticed an abnormal mass in the left NP.  Now when you see a mass, this typically is a tumor, most likely malignant.  I explained my concern, and took him to surgery for endoscopic eval and biopsies under anesthesia.

 

At the same time, I did a left myringotomy and tube to ventilate the ME, remove the fluid and improve his hearing.  He tolerated both procedures quite well with little postoperative pain.  He eventually had radiation therapy without chemotherapy, and hr tolerated this quite well.  Thus far, nearly two years later, he has remained disease-free (i.e., no return of cancer).

The lesson here returns to the fundamentals of medicine: getting a good history and doing a good physical exam, including the use of other methods at our disposal to complement the exam or referring to others to do so.  More importantly, this should reinforce seeking medical attention when things don’t seem right.  With COME, the vast majority will have benign causes and nasopharyngeal tumors are rare (I’ve seen about a dozen in the past 20+ years). 

 

©Randall S. Fong, M.D.

www.randallfong.com

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