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Case (81)


Geelle is a male  60 years old, came to hospital complaining  right facial pain, nasal tone of voice  and  right upper neck swelling  of 3 months  duration with  insidious onset  and  progressive course. There was a history of  nasal obstruction with occasionally nasal bleeding and impairment of hearing of right ear for the last month.

Examination: There was:
               -  Right multiple hard swelling deep to the sternmastoid muscle.
               - Right palatal paralysis.
               - Right ear drum was retracted.
              - Rinne`s test was negative in right ear.
              - Weber`s lateralized to right.

1. What is your most probably diagnosis? Give reasons?
2. What is the type of hearing loss and what is the cause?
3. Give three investigations and their possible finding.
4. What is the treatment?

1.Nasopharyngeal carcinoma.
2. conductive hearing los due to obstruction or invasion of the cancer.
3. CT to see the invasion.
nasopharyngoscopy to visualise and harvest biopsy.
ottoscope to visualize tympanic membrane and the ossicles.
The swelling of sternocleidomastoid muscle is due to the invasion of lymph nodes. The vagus nerve (plattopharyngeal branch) is invaded causing the paralysis of the right palate.
4. This is very serious dz and radiation is the mainstay but also requires surgery to dissect the affected lymph nodes and tissues. The hearing problem can be solved implanting a tube that opens to the eustacian tube.
Prognosis 40% survival as the cancer invaded other tissue outside.

 Excellent, Muraad, 15 marks. thank you very much.


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