Nasopharyngeal cancer

The nasopharynx is a small space just behind the nose, above the soft palate. Air passes through it, and the tubes that ventilate the middle ear open into it. A tumour that starts here does not interfere with breathing or swallowing for a long time and does not hurt; it makes itself known when it blocks the ear tube or when a lump appears in the neck. It is an uncommon cancer, very sensitive to radiotherapy and curable at an early stage, so the difference between a good and a bad outcome is usually settled in the first few months, while the person is still walking around with "an ear infection that won't clear" or "a lump on the neck".

How it usually starts

In most people the first thing to appear is a painless lump in the neck, below the angle of the jaw or a little higher, towards the ear. It is firm, does not hurt, does not go red, does not shrink and does not respond to antibiotics. That is the complaint people come with, while the nasopharynx itself stays silent.

The second way in is the ear. The tumour closes the ear tube, fluid builds up behind the eardrum, and the description is always the same: one ear blocked, sounds muffled, your own voice booming inside your head, sometimes ringing as well. A blocked ear in an adult with no cold beforehand is a reason to look at the nasopharynx rather than to wait for it to settle.

On the nasal side the picture is one-sided too: one nostril stops working, blood-stained discharge appears, there is blood in the mucus coughed up in the morning, and nosebleeds happen.

As the tumour grows and reaches towards the skull base, signs appear that a cold no longer explains:

• double vision, particularly when looking to one side;
• numbness of the cheek, the side of the nose, the upper lip or the gum, as though that patch had been anaesthetised;
• a persistent deep headache, behind the eye or at the back of the head;
• the mouth opens less and less and a large bite becomes difficult;
• the voice changes and swallowing becomes harder;
• weight falls away without dieting.

When waiting is not an option

None of these signs on its own means cancer: neck lumps are usually inflammatory, ears usually block after a cold, and a nose usually blocks because of a deviated septum. The difference lies in time and in sidedness. What matters is anything that lasts longer than three weeks, does not settle after an ordinary illness has been treated, and happens on one side only.

Arrange an appointment within days if:

• there is a firm, painless lump in the neck that has not gone in three weeks;
• one ear has been blocked for over a month, or hearing in it has clearly dropped;
• one side of the nose does not breathe and blood comes from it;
• part of the face has gone numb, or double vision has started.

Ask specifically for the nasopharynx to be examined. Looking at the throat with a tongue depressor or a mirror does not reach it: it lies above and behind everything visible through the mouth, and "your throat looks clear" means nothing here.

Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number is 112) if bleeding from the nose or mouth is heavy and does not stop after ten to fifteen minutes of pinching the nostrils, if breathing suddenly becomes difficult, if vision drops abruptly, or if a violent headache comes on with vomiting. A separate warning for anyone already on chemotherapy: a temperature above 38 °C during those weeks means contacting the team straight away, at night as well, and even if nothing else is wrong.

What raises the risk

In any individual case the cause is usually unknown, but the circumstances in which this tumour turns up more often are well mapped. None of them is a sentence — plenty of patients have not a single one.

• Epstein-Barr virus. Almost everyone has had it, usually in childhood or as glandular fever, and the overwhelming majority never develop a tumour. Yet the virus is present in the cells of this cancer almost without exception, and both the blood test and the follow-up are built on that fact.
• Ancestry. The disease is many times more common in people of southern Chinese and South-East Asian origin and in people from North Africa, and the raised risk persists in their children brought up in Europe.
• Salt-preserved food. Salted fish and meat eaten regularly and in quantity in early childhood carry a higher risk.
• Smoking and spirits.
• Work with hardwood dust and formaldehyde: joinery, furniture making, laboratories.
• The disease in a close blood relative.

Men are affected more often and the usual age is past forty, but unlike many other cancers this one also occurs in young people, so age is no reason to shrug off a one-sided symptom.

How the diagnosis is made

The diagnosis rests on two things: seeing the nasopharynx and obtaining a piece of tissue. Everything else shows how far matters have gone.

• Nasendoscopy — a slim flexible endoscope through the nose under local anaesthetic. The doctor sees the tumour itself, where it sits and how big it is. The diagnosis is neither confirmed nor ruled out without it.
• Biopsy — a fragment of tissue taken during that same endoscopy. Only this gives the final answer on whether there is a tumour and what type it is.
• MRI of the head and neck shows best whether the tumour has reached the skull base or is tracking along nerves; in this disease it tells you more than CT.
• CT and PET-CT are used to assess the neck nodes and look for spread elsewhere.
• Epstein-Barr virus DNA in the blood. The level reflects the bulk of the tumour, helps with the prognosis and is later the first thing to signal that the disease is returning.
• A hearing test and a dental assessment before treatment, which has a section of its own below.

What does not find this tumour: an ordinary look at the throat, blood tests "for tumour markers", a sinus X-ray or a neck ultrasound. The ultrasound will show the lump but not where it came from. Once a lump has been found, the right order is to look for the primary tumour in the nasopharynx first, rather than removing the node blind.

How it is treated

Radiotherapy is the mainstay. The nasopharynx is surrounded by delicate structures and hard to reach with a scalpel, while the tumour answers radiation very well, so the primary site is hardly ever operated on. Surgery is kept in reserve for neck nodes that do not disappear after treatment.

Radiotherapy is given in short weekday sessions over several weeks, and an overnight stay is not usually needed. Modern technique brings beams in from many angles, following the exact shape of the tumour and sparing the salivary glands, the eyes and the spinal cord — how severe the after-effects turn out to be depends directly on that.

For more advanced disease, chemotherapy is added before radiotherapy or alongside it, as infusions a few weeks apart. Combined treatment is harder to get through, but it raises the odds appreciably.

If the disease comes back or has spread, the options are further targeted radiotherapy, other chemotherapy regimens and drugs that take the brakes off the body's own immune system — a class that has changed the outlook in relapse over recent years.

Prognosis depends above all on stage. A tumour that has not left the nasopharynx and the nearby nodes is often cured by radiotherapy alone, and even with neck nodes involved the chances remain good. The difficult situation is disease that has travelled beyond the head and neck, which is the whole reason for the urgency about getting checked.

What to sort out before radiotherapy starts

See a dentist — this is not a formality. Irradiating the head and neck permanently changes the blood supply of the jawbone and the working of the salivary glands. Afterwards, taking a tooth out inside the treated field can leave the bone unable to heal: this is osteoradionecrosis, a serious complication that takes months to treat. Everything that needs extracting or filling is therefore done before the course begins, with time left for healing. The dentist will also make fluoride trays and explain how to brush from now on: without saliva, decay races ahead.

The rest of the preparation matters just as much. Talk about eating: during the course the throat hurts, taste disappears and weight drops fast, so a feeding tube is sometimes placed in advance — not because things are going badly, but to avoid losing strength halfway through. Have your hearing and your thyroid checked beforehand, so that there is something to compare with later. And stop smoking: smoking during radiotherapy worsens the inflammation of the lining and makes the disease more likely to return.

Side effects and life after treatment

During the course the usual troubles are a sore mouth and throat, thick saliva, loss of taste, reddened skin on the neck, nausea and fatigue. There is no point in enduring them quietly: the team adjusts pain relief, mouthwashes and anti-sickness medication, and pain controlled in time is what keeps a person eating.

Some consequences stay for a long while, and it is worth knowing about them in advance:

• a dry mouth, the commonest complaint; frequent sips of water, moisturising sprays and saliva substitutes all help;
• rapidly advancing tooth decay — hence lifelong fluoride and dental checks twice a year, with any extraction discussed with the cancer team first;
• a stiff jaw, prevented by daily mouth-opening exercises started early;
• hearing loss and a blocked feeling in the ear;
• an underactive thyroid, which develops months or years later and shows itself as tiredness, feeling cold and weight gain, so thyroid blood tests are done regularly;
• tightness and stiffness of the neck muscles, and changes in swallowing.

Follow-up is close: examinations with endoscopy and scans every few months at first, then further apart, along with monitoring of viral DNA in the blood. Between visits the rule is simple: any new one-sided sign — the ear blocking again, a lump in the neck, blood from the nose, numbness of the face — is a reason to be seen early rather than waiting for the next date.

Online consultation

Before a diagnosis, a remote appointment settles the main question: is this an ordinary story or one that calls for endoscopy. The doctor will ask which ear is blocked and for how long, whether a cold came first, whether there is a lump in the neck and whether it is changing, whether there is blood in the discharge, and will say which test to ask for and which specialist to see.

During treatment, side effects are handled well online: what to rinse the mouth with, what to do about thick saliva and weight loss, how to look after the skin of the neck, which signs need an urgent face-to-face review. Afterwards come the questions about dry mouth, teeth, hearing, thyroid hormones and what the latest results mean.

The limits are worth being clear about: a conversation on a screen cannot examine the nasopharynx, cannot take a biopsy and does not replace radiotherapy, and heavy bleeding, sudden breathing difficulty or a fever during chemotherapy call for urgent care rather than an online appointment.

This material is for information only and does not replace medical advice.