Section 8

55-year-old man from Hong Kong presents with left sided hearing loss and nasal obstruction

Describe two features of this tympanic membrane.

  • Dull tympanic membrane
  • Retraction
  • Fluid bubble

Which audiogram would be most consistent with this patient’s otoscopic examination?

  • 1 – conductive hearing loss in left ear
COnductive hearing loss
unnamed (14)
Normal hearing (1)
Otosclerisis (2)

What would you expect to find on testing Rinne’s and Weber’s tests, assuming the right ear has normal hearing?

  • Rinne’s: Right ear: positive (AC>BC), left ear: negative (BC>AC)
  • Weber’s: lateralises to the left

What examination would you like to perform and what pathology would you be concerned about?

  • Flexible nasoendoscopy to examine the post-nasal space
  • Concern about a nasopharyngeal tumour

Where would this most likely arise in the post-nasal space?

  • Fossa of Rossenmuller/pharyngeal recess
  • Postero-lateral nasopharynx

Name a viral risk factor for this condition.

Epstein-Barr Virus.

Describe Trotter’s triad.

  • Symptoms associated with advanced nasopharyngeal cancer due to invasion of lateral wall of the nasopharynx
  • Usually a triad of 
    • Unilateral conductive hearing loss due to middle ear effusion
    • Ipsilateral soft palate immobility due to direct invasion 
    • Trigeminal neuralgia affecting mandibular branches due to irritation to the trigeminal nerve via perineural invasion
  • Trismus may also occur
  • First described by Wilfred Trotter in 1911

Supporting Information

Nasopharyngeal carcinoma – 

  • Histology – squamous, squamous keratinising,  non-keratinising, or undifferentiated. 
  • EBV is a risk factor with a genetic predisposition
  • Salt fish – Hong Kong
  • Most originate fossa of rosenmuller – postero-lateral recess
  • Facial nerve and eustachian tube involvement
  • Presents with neck lump, otalgia, epistaxis
  • Levator veli palatini – opens Eustachian tube on swallowing. If infiltrated will reduce mobility of the palate. 
  • Trigeminal nerve irritation – pain over trigeminal area – hyperesthesia
  • Trotter’s triad-  Glue ear, reduced ipsilateral palate movement, trigeminal pain

Treatment – local radiotherapy +/- bilateral neck radiotherapy +/- radical neck dissections

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