Is Nasopharyngoscopy Necessary In Adult-Onset Otitis Media With Effusion?

QUESTION

In an area with low risk of nasopharyngeal carcinoma, is it necessary to perform nasopharyngoscopy in adults who present with isolated otitis media with effusion?

BACKGROUND

Adult-onset otitis media with effusion (AO-OME) is associated with common medical conditions such as upper respiratory tract infection (URI), sinusitis, allergic rhinitis, and adenoidal hypertrophy. It can also be a presenting feature of nasopharyngeal carcinoma (NPC) (1). While NPC is endemic in China and Southeast Asia, it is a very rare disease (<1 per 100,000) in the United States (1–2). Despite this, it is common for American otolaryngologists to recommend nasopharyngoscopy in patients with AO-OME in order to rule out NPC. With such a rare disease, one must ask if nasopharyngoscopy is essential in adults who present with isolated AO-OME.

LITERATURE REVIEW

Using several national cancer registries from 1993–2002, Chang and Adami showed that that NPC is a very rare disease outside the endemic areas in China, Southeast Asia, and Northern Africa. Specifically, based on the Surveillance, Epidemiology, and End Results (SEER) registry, incidences of NPC were 0.4 and 0.2 per 100,000 for US Caucasian males and females respectively. Similar figures were showed in developed countries such as Canada and Japan. However, American Chinese and Filipino in Hawaii and Los Angeles, as expected, had slightly elevated risks (3.7–10.7 for males and 1.6–3.8 per 100,000 for females) (2).

In patients who are eventually diagnosed with NPC, isolated OME is an uncommon sign. In a retrospective analysis of 4,768 patients with NPC in a high risk area, Lee and his colleagues found neck mass (75.8%) and nasal symptoms (discharge, bleeding, and obstruction) (73.4%) were the most common presenting symptoms. While aural symptoms (tinnitus, impaired hearing) presented in 62.2% of patients, only 19.1% had them as the initial symptom. Furthermore, only 1.1% of patients with NPC presented with isolated ear-related symptoms (1).

A case-series study of 87 adults with isolated OME in an endemic area, Ho and his colleagues reviewed results of their nasopharyngeal biopsies. The majority of patients were presented with hearing loss (97.7%) and ear fullness (70.1%). The most common causes of isolated OME in this study were URI (23.0%), allergic rhinitis (18.4%), sinusitis (17.3%). NPC was confirmed in 5 patients (5.7%), which include one case of squamous cell carcinoma and four cases of non-keratinizing carcinoma. Other etiologies were responsible for 12.6% of cases, and unknown etiologies were shown in 23.0% of biopsies (Figure 1a). Upon review of the existing literature and their data, the authors discussed that he incidence of nasopharyngeal tumors in adults with isolated OME ranged between 0.4–5.7% depending on the population studied (3).

Figure 1.

Incidences of different pathologies that present with isolated adult-onset otitis media. a) Data from endemic area; b) Data from low-risk areas

¹: The incidences presented are the average of two studies: Finkelstein et al and Robinson

While research on NPC is widely conducted in endemic areas, there is a paucity of data addressing the use of nasopharyngoscopy with biopsy in patients with AO-OME in low-risk areas, and all of such studies are underpowered. Finkelstein et al performed a prospective study of 167 consecutive patients with AO-OME. All patients underwent endoscopic examination of the nasopharyngeal space with careful examination of the Eustachian tube orifices. Sixty five patients also had CT scan of their skull base, neck, and paranasal sinuses. The most common causes of OME were paranasal sinus disease (67.1%), smoking-induced nasopharyngeal lymphoid hyperplasia, and adult-onset adenoidal hypertrophy (9.0%). Only eight patients (4.8%) were found to have head and neck cancers. Among those, three had lymphoma (1.8%), two had parapharyngeal space schwannomas (1.2%), two had NPC (1.2%), and one with known history of chronic lymphoid leukemia had leukemic infiltration of the nasopharynx (Figure 1b). However, the authors noted that nasal obstruction and headache preceded otologic symptoms in both patients with NPC (4).

Robinson reported similar findings in his case series of 94 adults with a discharge diagnosis of AO-OME. Only 46 patients (48.9%) were found to have nasal, nasopharyngeal, or sinus related pathologies. Most AO-OME cases were associated with sinusitis (16.0%), URI (8.5%), and allergic rhinitis (5.3%). Another 11.7% OME cases were caused by other benign conditions such as nasal polyps, nasopharyngeal cysts, and enlarged adenoids, etc… Seven cases of head and neck tumors were found (7.4%), among which four (4.3%) had NPC, two (2.1%) had metastases from breast cancers, and one (1.1%) had meningioma (Figure 1b). However, besides OME, all seven patients had other features of malignancy such as diplopia, headache, hoarseness, and nasal obstruction (5).

BEST PRACTICE SUMMARY

There is a lack of prospective randomized controlled trials addressing the role of nasopharyngoscopy in patients who present with isolated OME. Nasopharyngoscopy in patients who have OME in combination with other signs and symptoms suggestive of NPC appears to be a well-supported diagnostic measure. The available evidence would suggest that nasopharyngeal evaluation with biopsy could be expected to yield a diagnosis of neoplasia in 0.4–7.4% of all adults presenting with isolated OME depending on the ethnicity of the patient population. Whether routine nasopharyngoscopy alone (as opposed to routine biopsy) would effectively diagnose nasopharyngeal neoplasia in all such patients remains unclear. It is clear however that the routine use of nasopharyngoscopy in adults presenting with isolated OME frequently reveals contributory, benign nasopharyngeal pathology of varying severity in a significant proportion of patients. Given the limitations of the existing data on the use of nasopharyngoscopy in the workup of adults with isolated OME, the clinician should use clinical judgment and the presence of any additional signs and symptoms of nasopharyngeal pathology to guide the decision whether endoscopic examination of the nasopharynx in such patients is necessary.

LEVEL OF EVIDENCE

Information about incidences of NPC in low-risk, developed countries were obtained via a review of case-control studies (level 3a evidence). The current literature addressing the role of nasopharyngoscopy in isolated AO-OME in developed countries is small and has relatively poor level of evidence, making it hard to generate a solid evidence-based best practice recommendation. In this article, a case-series of AO-OME in endemic areas was used to compare with two case series addressing the features of NPC and the roles of nasopharyngoscopy in developed countries (level 4 evidence).