58-year-old male with ear pain

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).

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

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.