This present study clearly demonstrates a case of bilateral serous otitis media which was the only clinical finding in a patient who was initially thought to have otitic barotrauma. Thorough evaluation after the failure of initial treatment led to a diagnosis of nasopharyngeal cancer. The otologic manifestations of nasopharyngeal cancer are usually unilateral. Bilateral presentation is quite uncommon . Bilateral serous otitis media or Eustachian tube dysfunction as the only clinical manifestation of nasopharyngeal cancer is uncommon and rarely reported in the literature. A high index of suspicion is therefore needed to evaluate patients with bilateral serous otitis media or Eustachian tube dysfunction for possible nasopharyngeal cancer.
The otologic manifestations of nasopharyngeal cancer occur as a result of the sheer tumor bulk within the nasopharynx and paranasopharyngeal space extension [4, 5]. These manifestations may include Eustachian tube dysfunction, fluid accumulation within the middle ear (otitis media with effusion), conductive hearing loss, tinnitus and otalgia . These symptoms are usually unilateral and are more common in regions with a high incidence of the disease . It has been postulated that the altered Eustachian tube compliance in these patients is a result of cartilage erosion by the tumor and not necessarily the destruction of the tensor veli palatinus . Bilateral Eustachian tube dysfunction in nasopharyngeal cancer is rarely reported in the literature. It can occur if the tumor grows to obstruct the openings of the Eustachian tubes in the nasopharynx, especially in the exophytic or infiltrative morphological type. In that instance, the otologic presentation will initially be unilateral. In our patient, both ears were simultaneously affected after air travel. Usually, mild conductive hearing loss accompanies otitis media with effusion. However in this patient, the severe bilateral conductive hearing loss may be due to the summative effects of both the sheer bulk of the tumor in the nasopharynx and the otitic barotrauma on the Eustachian tube.
The hidden nature of the nasopharyngeal space poses diagnostic and therapeutic challenges, thus allowing significant spread of the disease before diagnosis . The inclusion of nasopharyngoscopy in the clinical setting has greatly increased early diagnosis of nasopharyngeal cancer with consequently improved prognosis of the disease . This was not done in our patient because nasopharyngeal cancer was not in our list of differentials. In a study by Grandawa et al. of 40 patients with nasopharyngeal carcinoma in north-eastern Nigeria, otologic symptoms were not noted. The clinical profile reported in these patients included cervical lymphadenopathy (72.5%), rhinorrhea (55%) and epistaxis (45%) . However, a study by Iseh et al. of 30 patients in north-western Nigeria reported clinical presentations of deafness and otalgia in 36.3% and 30% of patients, respectively. Other clinical presentations included cervical lymphadenopathy (93.3%), epistaxis (83.3%), nasal obstruction (66.7%), palatal swelling (26.7%), cranial nerve involvement (23.3%) and visual impairment (20%) . A study by Sham et al. of 237 Chinese patients with nasopharyngeal cancer showed that 41% of them had unilateral serous otitis media . This value is quite high and may be related to the fact that nasopharyngeal cancer is seen more commonly among Asians . The true incidence of this disease in Africa, however, is largely unknown: Nwaorgu et al. reported a steady increase in the disease occurrence over the last two decades in Nigeria . Inner ear symptoms, such as vertigo, in nasopharyngeal cancer are rare . In our patient, bilateral hearing impairment and tinnitus were the only presenting symptoms. Nasopharyngeal cancer is unlikely to be easily thought of as a possible diagnosis, especially when the symptoms occur after air travel. Our patient was initially treated for barotitis and only when the symptoms did not improve was she re-evaluated and a diagnosis of nasopharyngeal cancer confirmed.
Otitic barotrauma (barotitis) is a traumatic inflammation of the middle ear occurring as a result of pressure difference between the air in the middle ear and the external atmosphere, developing after ascent or, more usually, descent during air travel. It occurs because of the failure of the Eustachian tube to equilibrate middle ear and atmospheric pressure. It is quite common and presents with ear fullness, otalgia and deafness . Severe cases may result in tympanic membrane perforation and even round window perforation . It is an uncommon differential diagnosis of nasopharyngeal cancer . The treatment of nasopharyngeal carcinoma is chemoradiation. This was the treatment administered to our patient and she has shown remarkable improvement in her clinical condition to date. The observed significant improvement in hearing thresholds in the repeat pure tone audiogram may be a result of the combined effect of both the gross tumor excision during the biopsy and chemoradiation therapy, which might have relieved the Eustachian tube obstruction.