October 28, 2024

58-year-old male with ear pain

By Med-Challenger · 2 minute read

A 58-year-old male presents in the middle of the night complaining of a constant pain in his left ear that is now interfering with his ability to sleep. The patient’s ear exam is benign, but a lateral neck mass is noted (see image).

image (10)

Which of the following statements is correct?

In general, 30% of non-thyroid neck masses in adults are neoplasms
A lateral neck mass such as the one in the image with referred pain to the ear should prompt questioning about tuberculosis
Unilateral, referred ear pain in an adult is a retropharyngeal neoplasm until proven otherwise
The chart should reflect a cranial nerve exam, together with questioning about hoarseness, odynophagia, dysphagia, stridor, globus phenomena, and speech changes
This patient’s presentation is most consistent with a chronic pharyngeal infection from an odontogenic source

The correct answer is:

The chart should reflect a cranial nerve exam, together with questioning about hoarseness, odynophagia, dysphagia, stridor, globus phenomena, and speech changes.

This patient was suffering from a nasopharyngeal carcinoma that had metastasized to the lymph nodes in the sternocleidomastoid area.

In general, unilateral referred otalgia or persistent serous otitis media in an adult is a nasopharyngeal cancer (not a retropharyngeal cancer) until proven otherwise.

Other rules of thumb with regards to neck masses are:

Lateral neck masses are more likely to be malignant.
80% of non-thyroid neck masses in adults are neoplasms, of which 80% are malignant (80-80 rule).

The undiagnosed cancer patient will often not connect pertinent symptoms of a neoplasm together. Thus the clinician should perform and document a more general exam (beyond the patient's immediately symptomatic area) and review of systems when confronted with a mass that may be a tumor. A minimum HEENT review would include a cranial nerve exam and questioning about otalgia, hoarseness, odynophagia, dysphagia, stridor, globus phenomena, and new speech problems. The status of neck lymphnodes should also be remarked upon. The level at which an abnormal node occurs is in and of itself a clue to the location of the primary tumor.

Hoarseness in particular is an easily ignored complaint that may be the only presenting sign of a laryngeal or tracheal malignancy. Any hoarseness that has lasted for more than two weeks requires investigating or referral.

Pearls:

Globus phenomenon refers to the sensation of a mass in the throat.
Referred Otalgia: Unexplained ear pain in adults should raise suspicion for nasopharyngeal carcinoma.
80-80 Rule: 80% of non-thyroid neck masses are neoplasms; 80% of those are malignant.
Cranial Nerve Exam: Check cranial nerves and ask about hoarseness, dysphagia, and stridor when a neck mass is found.
Lateral Neck Masses: Lateral neck masses in adults are more likely to be malignant.
Early Referral: Early identification and referral for neck masses may improve outcomes.

References:

Marx: Rosen's Emergency Medicine, Concepts and Clinical Practice, 6th ed., 2006

Robert Dolan, MD, Associate Professor, Department of Otolaryngology, Boston University Medical Center, Case Study.

Additional Literature:

Molecular Biology of Head and Neck Cancer: Risks and Pathways. Stadler ME - Hematol Oncol Clin North Am - December, 2008; 22(6); 1099-1124

This question appears in Med-Challenger Emergency Medicine Review with CME.

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