Referred ear pain and the presentation of pharyngeal cancer
Pharyngeal cancer, cancer of the throat, classically presents with painful or difficult swallowing, a neck lump and referred otalgia (ear pain although the ear is healthy).
Remember
Ear pain on one side with a normal ear and difficulty swallowing should make you look at the throat, because the glossopharyngeal nerve (cranial nerve IX) carries sensation from the oropharynx (the part of the throat behind the mouth) and from the middle ear (the part of the ear behind the eardrum).
Pharyngeal cancer may arise in the nasopharynx (the throat behind the nose), the oropharynx (behind the mouth) or the laryngopharynx (behind the voice box). It is often silent early on, so patients commonly present with advanced disease.
The tumour involves the lining and muscles of the throat that coordinate swallowing. Swallowing can be painful (odynophagia) or difficult (dysphagia). A neck lump from enlarged lymph nodes may also be present.
Ear pain can also be felt in a normal ear. This is referred otalgia: otalgia means ear pain, and referred means that the problem is not in the ear. The glossopharyngeal nerve (cranial nerve IX) carries sensation from the oropharynx and, through a branch called the tympanic nerve, from the middle ear. Signals from both areas converge, so the brain cannot tell where the pain began and places it in the ear.
Since the ear itself is healthy, otoscopy (looking into the ear with a light) is normal. Persistent unilateral ear pain with dysphagia and a normal ear in an adult is a red flag, and it needs a head and neck cancer assessment. The throat and neck should be examined, and nasoendoscopy (a thin flexible camera passed through the nose to view the throat) can show the mass directly.
Key facts
- Presentation
- the disease is often silent early on, so patients commonly present with advanced disease.
- Swallowing symptoms
- odynophagia (painful swallowing) and dysphagia (difficulty swallowing) are classic symptoms.
- Referred otalgia
- ear pain with a normal ear because the problem is elsewhere in the head and neck, for example a tumour.
- Shared nerve
- the glossopharyngeal nerve (cranial nerve IX) carries sensation from the oropharynx and, through the tympanic nerve, from the middle ear.
- Neck lump
- a neck lump from enlarged lymph nodes may also be present.
- Throat and neck
- unexplained ear pain with a normal ear means the throat and neck need examining.
Exam traps
- Hoarseness is the commonest symptom of cancer arising in the voice box (laryngeal cancer), so it is not the classic first symptom of pharyngeal cancer, because the pharynx is the passage used for swallowing.
- A painless mass felt in the mouth is how oral cancer usually presents, not pharyngeal cancer, because the pharynx lies behind the mouth and its tumours are more likely to cause swallowing symptoms.
- Lymph node metastases in the neck can cause a neck lump, but nodal disease does not explain the ear pain directly. The ear pain is referred pain through a nerve supply that the throat and ear share.
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