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)

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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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