Introduction

Nasopharyngeal carcinoma (NPC) accounts for about 0.6 per cent of all malignancies. It demonstrates a distinct gender, racial and geographic distribution, which is reflective of its multifactorial aetiology.^{Reference Chua, Wee, Hui and Chan1,Reference Ferlay, Soerjomataram, Dikshit, Eser, Mathers and Rebelo2} Risk factors include Epstein–Barr virus, human papilloma virus, tobacco use, alcohol consumption, and several dietary practices including the intake of preserved foods.^{Reference Chua, Wee, Hui and Chan1} Worldwide, there are around 86 000 cases and 50 000 deaths annually; however, in the western world NPC is rare, with an incidence of only 0.5–2 cases per 100 000, with a 2–3 fold higher risk in males.^{Reference Chang and Adami3}

The most common presenting symptoms are neck lumps, headache, diplopia, epistaxis and facial numbness.^{Reference Chua, Wee, Hui and Chan1,Reference Suzina and Hamzah4} The classical Trotter's triad of unilateral conductive hearing loss, ipsilateral otalgia or facial pain, and ipsilateral paralysis of the soft palate represents a very rare presentation of the disease. In patients presenting with unilateral serous otitis media, nasopharyngeal malignancy must be considered as a potential underlying cause. It is identified in 0.4–7.4 per cent of patients who present with isolated serous otitis media.^{Reference Dang and Gubbels5} Furthermore, serous otitis media is the sole presenting complaint in 0–1.5 per cent of nasopharyngeal tumour patients,^{Reference Gaze, Keay, Smith and Hardcastle6–Reference Robinson8} and is one of the presenting complaints in 26–46 per cent of cases.^{Reference Dempster and Simpson9}

Serous otitis media is a recognised presentation of Eustachian tube dysfunction secondary to post-nasal space pathology. Therefore, examination of the nasopharynx is an essential part of the investigation of any patient presenting with serous otitis media. Whenever a suspicious lesion is identified during nasendoscopy, biopsy is unquestionably warranted. However, the question as to whether biopsy is required in cases of isolated serous otitis media when nasendoscopy findings are normal, so called ‘blind biopsy’, is yet to be answered definitively. The uncertainty involved and concern of missing a cancer diagnosis means that it is common practice in many centres to perform a routine nasopharyngeal biopsy regardless of nasendoscopy findings or the presence of additional clinical manifestations of NPC. At present, there are no guidelines and no clear indications for when a nasopharyngeal biopsy should be performed.

This question has important implications for many aspects of patient care. There is evidence that waiting on an investigation for a possible cancer diagnosis has a significant impact on patients’ psychological wellbeing.^{Reference Poole, Hood, Davis, Monypenny, Sweetland and Webster10} Furthermore, despite evidence that local anaesthesia and general anaesthesia for biopsies of the post-nasal space have similar sensitivities for diagnosing NPC (95.1 per cent vs 95.6 per cent respectively),^{Reference Waldron, Van Hasselt and Wong11} surgical skill and equipment availability means that many centres still perform post-nasal space biopsy under general anaesthetic. This has notable financial consequences, as well as ethical implications regarding the risk–benefit of a general anaesthetic.

This 10-year review of adult patients with serous otitis media aimed to determine whether there is a role for blind biopsies of the nasopharynx in this country, which has a low incidence of NPC.