## Diagnosis: Nasopharyngeal Carcinoma (NPC) ### Clinical Presentation **Key Point:** The classic triad of nasopharyngeal carcinoma is epistaxis, cervical lymphadenopathy, and otologic symptoms (conductive hearing loss from Eustachian tube obstruction). This patient presents with: - Epistaxis (vascular mass) - Cervical lymphadenopathy (nodal metastasis) - Conductive hearing loss (Eustachian tube obstruction by primary tumor) - Geographic risk (Tamil Nadu — endemic region in India) ### Pathological Hallmark **High-Yield:** EBV-encoded RNA (EBER) in situ hybridization positivity is pathognomonic for undifferentiated nasopharyngeal carcinoma (WHO Type III). This is the most common histologic type worldwide and is strongly associated with EBV infection, particularly in endemic regions (Southeast Asia, North Africa, Southern China). ### Staging & Workup | Feature | Significance | |---------|-------------| | Cervical node (2 cm) | N1 disease (metastatic) | | Nasopharyngeal mass | T-stage requires imaging (CT/MRI) | | EBER+ undifferentiated histology | Confirms NPC; guides prognosis | | Conductive hearing loss | Pathognomonic for NPC (Eustachian tube involvement) | **Clinical Pearl:** Conductive hearing loss in an adult with nasopharyngeal mass is NPC until proven otherwise. The tumor obstructs the fossa of Rosenmüller and blocks the Eustachian tube orifice. ### Next Steps 1. MRI nasopharynx + neck (staging, soft tissue detail) 2. CT chest/abdomen (distant metastasis screening) 3. PET-CT (if advanced disease suspected) 4. EBV serology (VCA-IgA, EBNA) — prognostic marker **Mnemonic:** **NOPE** = Nasopharyngeal carcinoma presents with **N**asal epistaxis, **O**tic symptoms (hearing loss), **P**haryngeal mass, **E**BV association. 
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