What neoplastic disease can cause bilateral serous middle‑ear effusion in a 54‑year‑old woman?

Nasopharyngeal Carcinoma is the Primary Neoplastic Cause of Serous Middle Ear Effusion

In a 54-year-old woman with bilateral serous middle ear effusion, nasopharyngeal carcinoma must be excluded as the underlying cause, particularly when the effusion is unilateral, persistent, or occurs without other obvious infectious etiology. 1

Primary Mechanism of Malignancy-Related Middle Ear Effusion

• Nasopharyngeal carcinoma causes middle ear effusion through Eustachian tube obstruction, either by direct tumor invasion of the tube orifice, compression from paranasopharyngeal extension, or displacement of the cartilaginous Eustachian tube. 2, 3

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly identifies unilateral serous otitis media as a red flag for nasopharyngeal malignancy, particularly when accompanied by ipsilateral hearing loss. 1

• Tumor displacement of the Eustachian tube is highly significant (p < 0.00001) in producing middle ear effusion, even more than direct invasion in some cases. 3

Clinical Presentation Pattern

• Approximately 33% of patients with nasopharyngeal carcinoma present with middle ear effusion, though it is the sole manifestation in only 2% of cases at initial consultation. 4

• In patients with persistent unilateral middle ear effusion and normal nasopharyngoscopy, 63.3% had malignant tumors and 32.9% had benign tumors causing the effusion through occult skull base involvement. 5

• The effusion results from paranasopharyngeal tumor extension, erosion of the petrous temporal bone, and obliteration of the pharyngeal recess—all significantly associated with serous otitis media development. 2

Critical Red Flags Requiring Malignancy Workup

Age >40 years is a major risk factor for head and neck squamous cell carcinoma, making this 54-year-old patient high-risk. 1

Unilateral presentation is particularly concerning—while the question mentions bilateral effusion, any asymmetry or unilateral hearing loss warrants aggressive investigation. 1

Additional suspicious features include:

• Recent hearing loss ipsilateral to any neck mass suggests nasopharyngeal malignancy with middle ear effusion 1
• Nasal obstruction and epistaxis may indicate ulcerated nasopharyngeal malignancy 1
• Otalgia with normal ear examination represents referred pain from the pharynx 1
• Presence of a neck mass (firm, >1.5 cm, reduced mobility, nontender) dramatically increases malignancy likelihood 1

Diagnostic Algorithm

Step 1: Detailed nasopharyngoscopy is mandatory to visualize the nasopharynx, Eustachian tube orifice, and pharyngeal recess for masses or asymmetry. 1

Step 2: Cross-sectional imaging with contrast CT or MRI should be ordered immediately for any patient >40 years with persistent middle ear effusion, even with normal nasopharyngoscopy, as occult skull base lesions may not be visible endoscopically. 1, 5

• MRI is superior for detailing tumor spread patterns along the Eustachian tube, levator palatini muscle invasion, and displacement of cartilaginous structures. 3
• Coronal imaging is essential to identify intracranial or extracranial-infratemporal lesions causing Eustachian tube compression. 5

Step 3: Biopsy under general anesthesia is indicated if imaging shows suspicious findings or if clinical suspicion remains high despite normal initial workup. 4

Other Neoplastic Causes (Less Common)

Beyond nasopharyngeal carcinoma, occult skull base lesions causing persistent unilateral middle ear effusion include:

• Benign tumors (32.9% of occult cases): meningiomas, schwannomas, paragangliomas 5
• Internal carotid artery aneurysms (3.8% of cases) can compress the Eustachian tube 5
• Metastatic disease to cervical lymph nodes from distant primaries may present with neck mass and referred otalgia 1

Critical Pitfall to Avoid

Never place ventilation tubes in adults with unexplained persistent middle ear effusion without first excluding malignancy through imaging. 5 The cost-effectiveness of routine nasopharyngeal biopsy in isolated middle ear effusion without other symptoms is questionable (0.4% yield), but imaging should always precede surgical intervention. 4

Nasopharyngoscopy alone is insufficient—it cannot identify intracranial pathology (30.4% of cases) or extracranial-infratemporal lesions (27.8% of cases) that cause Eustachian tube dysfunction. 5

Risk Stratification for This Patient

This 54-year-old woman requires:

• Immediate nasopharyngoscopy with careful examination of the nasopharynx, Eustachian tube orifices, and pharyngeal recesses bilaterally 1
• Contrast-enhanced MRI of the skull base and neck to evaluate for nasopharyngeal carcinoma or other occult lesions, even if nasopharyngoscopy appears normal 3, 5
• Assessment for tobacco/alcohol use, unexplained weight loss, dysphagia, or other head and neck cancer symptoms 1

The bilateral nature of the effusion does not exclude malignancy—nasopharyngeal and midline oral cavity cancers can cause bilateral cervical metastases and bilateral Eustachian tube dysfunction. 1